Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to failure to follow Enhanced Barrier Precautions (EBP) during wound care. Resident #16, admitted on 09/24/25, had diagnoses including muscle weakness, a pressure ulcer of the right buttock, infrarenal abdominal aortic aneurysm, and restless legs syndrome. A Minimum Data Set dated 02/18/26 documented memory impairment, total dependence on staff for all ADLs, and continuous bowel and bladder incontinence. Physician orders dated 02/24/26 directed staff to wear gloves and a gown when providing treatment to the resident’s sacral wound, which included cleansing with normal saline, patting dry with gauze, applying calcium alginate, and covering with a super absorbent dressing every day shift and as needed. On 03/03/26 at 2:15 P.M., surveyors observed wound care being performed on Resident #16 by LPN #838 and LPN #833. A sign posted outside the resident’s room indicated the resident was on EBP. Both LPNs gathered treatment supplies, entered the room, and donned gloves but did not put on gowns while completing the wound treatment. In interviews immediately following the observation, LPN #838 acknowledged the resident was on EBP and confirmed she should have worn an isolation gown during the treatment. LPN #833 confirmed she had not worn a gown and was unable to state why a gown was required, stating she believed only gloves were necessary. Review of the facility’s Transmission-Based (Isolation) Precautions policy, dated 09/01/22, showed that EBP, including gown use, are required when completing a dressing change on a wound or pressure ulcer.
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