Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Nurse #1 failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during wound care for a resident with an unstageable pressure injury. According to the facility's policy, staff are required to don both gloves and a gown when performing high-contact care activities for high-risk residents, such as those with chronic wounds. During an observation, Nurse #1 entered the resident's room, performed hand hygiene, and wore gloves throughout the wound care process, but did not wear a gown at any point. The resident involved had a documented unstageable pressure injury and was considered high-risk under the facility's EBP policy. Nurse #1 acknowledged during an interview that she had received training on EBP and was aware of the requirement to wear a gown during wound care, but stated she forgot due to being nervous. The Director of Nursing and the Administrator confirmed that Nurse #1 had been trained and should have worn a gown during the procedure.