The resident suffered from multiple serious conditions including a non-pressure chronic ulcer on the left foot, a pressure ulcer in the sacral region, and a stage 3 pressure ulcer on the left heel. The facility had placed the resident under Enhanced Barrier Precautions in August 2024, requiring staff to wear both gowns and gloves during high-contact care activities due to chronic wounds and an indwelling device.
On May 19 at 4:30 p.m., inspectors observed the nurse gathering supplies outside the resident's room, where visible Enhanced Barrier Precautions signage was posted on the door. The nurse entered the room, performed hand hygiene and put on gloves, then proceeded with wound care.
She never put on a gown.
The next day, inspectors interviewed the nurse about the violation. She confirmed the resident was on Enhanced Barrier Precautions because of wounds and an indwelling device. She admitted she had failed to apply the required gown before providing direct care to the resident's wounds.
"She should have," the nurse told inspectors.
The facility's registered nurse supervisor confirmed staff expectations during a May 21 interview. She stated she expected staff to properly put on personal protective equipment when a resident is on Enhanced Barrier Precautions. The supervisor confirmed staff were required to wear both gowns and gloves when performing wound care and catheter care.
Enhanced Barrier Precautions represent a heightened level of infection control designed to protect both residents and healthcare workers from the spread of dangerous pathogens. The precautions are particularly critical for residents with chronic wounds, which create open pathways for infection, and indwelling devices like catheters, which can harbor bacteria.
The nurse's failure to follow the protocol occurred despite multiple safeguards the facility had put in place. The resident's physician had specifically ordered Enhanced Barrier Precautions eight months earlier. Clear signage was posted outside the resident's room. The facility's own policies required gown use during wound and catheter care.
Stage 3 pressure ulcers, like the one affecting this resident's left heel, represent serious wounds that extend through the full thickness of skin and into underlying tissue. These wounds are particularly vulnerable to infection and can lead to life-threatening complications if proper infection control measures are not followed.
The resident's multiple chronic wounds created an especially high-risk situation. Non-pressure chronic ulcers on the foot, combined with pressure ulcers in the sacral region and heel, meant the resident had several open wound sites that required careful, sterile treatment.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting some residents at the facility. The finding suggests the infection control breakdown extended beyond this single incident, raising questions about staff training and supervision of Enhanced Barrier Precautions throughout the facility.
The nurse's admission that she "should have" worn the gown indicates she understood the requirement but chose not to follow it. This conscious decision to skip a critical safety step occurred while treating one of the facility's most vulnerable residents.
Healthcare-associated infections remain a leading cause of illness and death in nursing homes, with residents particularly susceptible due to advanced age, compromised immune systems, and multiple medical conditions. Enhanced Barrier Precautions serve as a crucial defense against these preventable infections.
The resident at Heritage Healthcare continues to live with multiple chronic wounds while receiving care from staff who demonstrated they may not consistently follow the infection control protocols designed to protect them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Healthcare of Hammond from 2025-05-21 including all violations, facility responses, and corrective action plans.
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