Failure to Implement Enhanced Barrier Precautions During Wound Care for Infected Pressure Injury
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper infection prevention and control practices for a resident with advanced pressure injuries and a documented wound infection. The resident, who was rarely/never understood per the MDS and had a history of cerebral infarction due to embolism of the left carotid artery, was readmitted from home with a worsening sacral pressure ulcer that progressed from stage 3 to stage 4. A wound culture collected on 03/10/2026 and reported on 03/13/2026 showed heavy growth of Escherichia coli and Proteus mirabilis, and the resident was started on Ciprofloxacin. Active orders included a Foley catheter for urinary incontinence and wound healing and treatment orders for a stage 4 sacral pressure injury. Despite these conditions, during an observation of wound care on 03/17/2026, there was no EBP signage on the resident’s door, and the LPN performing the dressing change wore gloves but did not don a gown. During the observed wound care, the LPN performed hand hygiene, but the handwashing duration was approximately 10 seconds during care and 7 seconds after completion, which did not meet expected standards. The Nurse Practitioner acknowledged awareness of the draining wound and Foley catheter but stated she did not order EBP, indicating that nursing staff typically initiate those precautions. An RN confirmed that EBP should be implemented for all wound care, especially for advanced pressure injuries, and that the nurse providing wound care is responsible for following physician orders and evidence-based standards. The Licensed Nursing Home Administrator acknowledged that, based on the resident’s sacral pressure injuries and documented infection requiring antibiotics, the LPN should have ensured EBP practices were consistently implemented. The LPN later stated she typically used gloves and standard precautions, did not recognize the need for additional transmission-based precautions, was unaware that a gown was required for this resident during wound care, and confirmed there was no EBP signage posted at the time of treatment.
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