Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves failure to implement the facility’s infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy for high-contact resident care activities such as wound care. The facility’s policy, last reviewed on 03/01/2026, requires staff to use gown and gloves during EBP and to change gloves between cleaning and applying ointments or dressings. Resident #2, admitted on 09/03/2025 with a primary diagnosis of Acute Respiratory Failure with Hypoxia, had an order and care plan in place for EBP in relation to wound care. On 03/16/2026 at 2:25 p.m., during wound care for Resident #2, S6 TXRN did not wear a gown and did not change gloves between cleaning the wounds and applying ointments and powder, contrary to the EBP protocol. Resident #3, admitted on 07/02/2024 with a primary diagnosis of Restless Legs Syndrome, also had an order and care plan for EBP. On 03/16/2026 at 2:45 p.m., during wound care for Resident #3, S6 TXRN again failed to follow EBP protocol by not wearing a gown and not changing gloves between cleaning and redressing the wound. In an interview on 03/16/2026 at 3:15 a.m., S2 CorpRN confirmed that EBP procedures require direct care staff to wear a gown and gloves during wound care and that S6 TXRN should have worn a gown and changed gloves after cleaning a wound and before applying clean dressings or ointments, as required by facility policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.