Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its Enhanced Barrier Precautions (EBP) protocol during wound care for Resident #2, who had an open back wound requiring treatment with calcium alginate with silver and a foam bordered dressing. On 3/3/26 at 1:32 p.m., a Treatment Nurse performed wound care in a room where EBP signage and PPE, including a red sign indicating the need for a personal care gown and gloves, were posted outside the resident’s room. The Treatment Nurse knocked, entered, assessed the resident’s pain, performed hand hygiene, and donned gloves, but did not put on a gown at any point during the wound care procedure. The nurse removed the old dressing, cleansed the wound per physician orders, applied the ordered dressings, and disposed of supplies, changing gloves and performing hand hygiene between steps, but never donned a gown despite the posted EBP requirements. During an interview later that afternoon, the Treatment Nurse stated that EBP stands for enhanced barrier precautions and acknowledged that EBP includes wearing a gown and gloves when providing care, specifically for open wounds and for urinary catheter or colostomy care. The nurse explained that she forgot to put on a gown because she was focused on the resident’s pain, and stated that she usually wears a gown and gloves when performing wound care, recognizing that EBP is important to prevent cross contamination, spread of bacteria, and for infection control. In a separate interview, the DON stated that when a resident is on EBP, staff are expected to wear a gown, gloves, and mask or face shield if needed when providing direct care, and that EBP is necessary for residents with open wounds, urinary catheters, PICC lines, and PEG tubes. The facility’s Enhanced Barrier Precautions policy indicated that EBP is an infection control intervention using targeted gown and glove use during high-contact resident care activities to reduce MDRO transmission, to be used in conjunction with standard precautions.
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