The September 9 violation at Autumn Care of Waynesville occurred while the nurse performed an elaborate wound cleaning process on a resident's left heel injury. Federal inspectors watched as she entered the room without the required gown, despite facility policy mandating both gloves and gown for high-contact care activities involving high-risk residents.
The resident had an unstageable pressure injury, placing him in the high-risk category under the facility's Enhanced Barrier Precautions policy. The policy, last revised in May, specifically requires staff to put on both gloves and gown before starting high-contact activities and remove them before leaving the room.
Inspectors observed the 10:38 AM wound care session in detail. The nurse performed hand hygiene and put on gloves. She removed the soiled dressing, took off her gloves and washed her hands again. She put on new gloves, washed and dried the wound, then removed those gloves. After another round of hand hygiene, she put on fresh gloves, applied skin preparation, placed clean gauze over the wound, covered it with a pad and more gauze, then secured everything with tape. She removed her gloves and performed final hand hygiene.
Throughout the entire process, she never wore a gown.
Twelve minutes later, inspectors interviewed the nurse about what they had witnessed. She admitted she had forgotten to wear the gown during wound care. She acknowledged receiving infection prevention education on Enhanced Barrier Precautions and knew she was supposed to follow the protocol during wound care.
Her explanation was simple: her nerves had gotten the better of her.
The facility's Enhanced Barrier Precautions policy targets residents with chronic wounds and indwelling devices, recognizing their elevated infection risk. These precautions go beyond standard infection control measures, requiring additional protective equipment during what the policy terms "high contact care activities."
The Director of Nursing and Administrator, interviewed together that afternoon, confirmed the nurse had received infection prevention training and should have worn a gown during the wound care procedure. They characterized the violation as a human mistake caused by nervousness.
Federal inspectors cited the facility for failing to implement its infection prevention and control program. The violation affected what inspectors classified as "few" residents, though the inspection report focused on the single observed incident involving the resident with the heel pressure injury.
The inspection was conducted in response to a complaint, though the specific nature of that complaint was not detailed in the federal report. Inspectors classified the harm level as minimal harm or potential for actual harm.
Enhanced Barrier Precautions represent a relatively recent addition to nursing home infection control protocols, designed to prevent transmission of resistant organisms and protect vulnerable residents. The precautions require facilities to identify high-risk residents and implement additional protective measures during care activities most likely to spread infection.
Pressure injuries, also known as bedsores, develop when sustained pressure reduces blood flow to skin and underlying tissue. Unstageable pressure injuries, like the one affecting the Waynesville resident, involve tissue damage so extensive that inspectors cannot determine the depth of the wound. These injuries carry significant infection risk and require careful wound management.
The wound care procedure the nurse performed followed proper technique in most respects. She changed gloves multiple times, performed hand hygiene between each step, and followed appropriate wound cleaning protocols. The missing gown represented the sole deviation from required infection control practices.
Autumn Care of Waynesville now faces federal oversight to ensure compliance with infection prevention requirements. The facility must submit a plan of correction addressing how it will prevent similar violations and ensure staff follow Enhanced Barrier Precautions consistently.
The incident highlights the gap between policy knowledge and practice implementation in nursing home settings. Despite receiving proper training and acknowledging the requirements, the nurse's momentary lapse created a potential infection risk for a vulnerable resident.
For the resident with the heel pressure injury, the violation meant exposure to whatever pathogens the nurse might have carried on her clothing during the extended wound care session. The consequences of that exposure remain unknown.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Care of Waynesville from 2025-09-09 including all violations, facility responses, and corrective action plans.