Failure to Implement Enhanced Barrier Precautions and Proper Wound Care Infection Control
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program, including proper implementation of Enhanced Barrier Precautions (EBP) for residents with wounds. For one male resident with a disrupted external surgical wound, physician orders specified EBP only for wound care once daily and did not include a general EBP order or directions for use during all high-contact activities. His care plan indicated EBP for a midline IV access and a right leg wound, with instructions that staff must use gowns and gloves during high-contact resident care activities that could result in transfer of multidrug-resistant organisms (MDROs), but the physician orders did not align with this broader requirement. For a female resident with a non-pressure chronic ulcer of the back and a sacral surgical wound, physician orders also limited EBP use to once-daily wound care, while her care plan called for EBP for both a colostomy stoma and sacral wound, again specifying gown and glove use during high-contact activities. The Director of Nursing later acknowledged that EBP was intended for high-contact activities such as wound care, dressing, bathing, transferring, and changing linens, and that the EBP orders for both residents were written too narrowly, specifying only wound care instead of all high-contact activities as outlined in the facility’s EBP policy and CDC guidance. During an observed wound care procedure for the female resident on EBP, an LVN failed to don the required PPE gown before entering the resident’s room and did not bring a trash bag into the room, where no trash bag was available. The LVN removed the old dressing and dirty gloves and placed them on the clean barrier with clean wound care supplies, instead of disposing of them in a trash bag. She performed inadequate wound cleansing by dabbing the wound a few times with Dakins-soaked gauze and dry gauze rather than cleansing from the cleanest to dirtiest area, and she failed to perform hand hygiene between glove changes. After completing wound care, she washed her hands with soap for only 4–5 seconds, below the facility policy requirement of at least 20 seconds, and disposed of contaminated trash outside the resident’s room. These observed actions did not comply with the facility’s EBP policy, hand hygiene policy, or CDC recommendations for PPE availability and use.
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