Failure to Use Required PPE and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policy for transmission-based precautions and Enhanced Barrier Precautions (EBP) during wound care for two residents. The facility’s policy, revised in June 2024, requires EBP, including appropriate PPE such as gloves and gowns, during high-contact resident care activities for residents with chronic wounds. One resident had diagnoses including Alzheimer’s disease, venous insufficiency, localized edema, and a non-pressure chronic ulcer on the right foot, with an active order for treatment of a lymphademic wound on the left third toe. This resident’s care plan specifically included an intervention for EBP due to an open wound per protocol. During an observed wound treatment, the licensed staff member performing the care wore only gloves and did not wear a protective gown, despite acknowledging that the resident was on EBP and that appropriate PPE should have included both gloves and a gown. The Infection Preventionist confirmed that the appropriate PPE was not used. A second resident had a documented sacral pressure ulcer. During an observed wound treatment for this resident, the licensed staff member performing the care was also not wearing appropriate PPE. The Infection Preventionist confirmed that this staff member did not wear the required PPE and failed to follow transmission-based precautions during the wound treatment. These observations, along with staff interviews and review of the facility’s policy and resident records, led surveyors to determine that the facility failed to follow transmission-based precautions and implement EBP in accordance with the residents’ care plans and infection prevention protocols, creating the potential for cross-contamination and placing the two residents at risk for transmission of infectious organisms.
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