F0880

E

Failure to Follow Enhanced Barrier Precautions and Aseptic Wound Care Practices

Dallas, Texas Survey Completed on 02-21-2026

Penalty

No penalty information released

Summary

The facility failed to maintain an effective Infection Prevention and Control Program when staff did not follow Enhanced Barrier Precautions (EBP), proper hand hygiene, or appropriate handling of wound care supplies during wound care for two residents. One resident was a male with quadriplegia and protein malnutrition, admitted in November 2025, who had multiple chronic wounds requiring weekly visits from a wound care physician and was care planned for EBP, including use of gown and gloves for wound care and other high-contact activities, and posting of an EBP sign at the room entrance. During an observation, an RN prepared multiple wound care supplies outside the resident’s room, including border dressings, 4x4 gauze, normal saline syringes, hydrogel in a medication cup, and collagen powder in another cup, then entered the room with a CNA where an EBP sign was posted.

Inside the room, the RN placed the wound care supplies directly on the bedside table without cleaning the surface or using a barrier. The RN and CNA washed their hands and donned gloves but did not put on gowns despite the resident being on EBP. For the left inner knee wound, the RN removed the old dressing and, with the same gloves, picked up a saline syringe and gauze to clean the wound, then used a gloved finger to dip into the hydrogel cup and apply it to the wound, and did the same with the collagen powder before covering the wound with a border dressing. The RN then removed gloves and re-gloved without performing hand hygiene before proceeding to the right outer ankle wound, where she again used a saline syringe and gauze, laid the partially used saline syringe back on the bedside table with other supplies, opened a package of calcium alginate with the same soiled gloves, applied it to the wound, and covered it with a border dressing. The RN again removed gloves and re-gloved without hand hygiene before performing sacral wound care, using the previously used saline syringe and gauze to clean the wound and applying collagen powder with her gloved finger, followed by calcium alginate and a border dressing. Only after completing all wound care did the RN remove gloves, perform hand hygiene, and leave the room, while the CNA assisted with repositioning and offloading, then removed gloves and performed hand hygiene.

For the second resident, a male with metabolic encephalopathy and diabetes admitted in April 2024, an LVN was observed preparing wound care supplies at the treatment cart, including a large package of 4x4 gauze, a tube of hydrogel ointment, tubes of normal saline, and a border gauze dressing. The LVN placed these supplies on the resident’s bedside table without cleaning the table or using a clean field. The LVN washed her hands, donned gloves and a gown, and removed the old dressing from a right upper thigh wound. She then removed her gloves and re-gloved without performing hand hygiene before pulling 4x4 gauze and opening a tube of normal saline to clean the wound. After cleaning, she again removed gloves and re-gloved without hand hygiene, requested a smaller border dressing from the DON, and, upon receiving it, opened the dressing and a tube of hydrogel, squeezing hydrogel onto the dressing and then placing the open tube of hydrogel on the bedside table without closing the lid. After applying the dressing, the LVN removed her gown and gloves, washed her hands, and returned the partially used package of gauze, the open tube of hydrogel, and the unused large border dressing to the treatment cart. Facility policies on EBP and fundamentals of infection control required targeted gown and glove use for residents with wounds, hand hygiene before and after resident contact and after glove removal, and setting up wound care supplies on a clean field, with unused supplies that entered the resident’s room to be discarded.

Interviews confirmed staff awareness of some, but not all, of these requirements. The RN acknowledged that any resident with a wound required EBP and recognized she had not worn a gown, stating she had simply forgotten and was not aware she had to set up wound care supplies on a clean field, believing she only needed to change gloves between wounds. The CNA stated she had received training on EBP and knew that residents with a Foley catheter or wound required gown and gloves, but said she forgot to put on a gown when assisting with turning the resident. The LVN stated she knew she was supposed to change gloves when moving from cleaning to treating the wound and should have performed hand hygiene, but was not aware she had to set up supplies on a clean field or that unused supplies brought into a resident’s room could not be returned to the treatment cart. The DON stated that staff were expected to change gloves and perform hand hygiene before going from dirty to clean, before entering and leaving a resident’s room, to follow EBP protocols for residents with posted signs, to set up supplies on a clean field, to avoid applying wound treatments with gloved hands, and to discard any unused supplies brought into a resident’s room, and stated that failing to follow these protocols placed residents at higher risk of infections.