RENO, NV - A federal inspection at Life Care Center of Reno revealed the facility failed to follow its own infection control protocols for a resident receiving treatment for chronic wounds, potentially placing other residents at risk of infection transmission.
Missing Infection Control Measures
Federal surveyors conducting an inspection on August 1, 2024, discovered that a resident with two chronic, non-healing wounds was not receiving care under Enhanced Barrier Precautions (EBP), despite facility policy requiring these protections. The resident had documented wounds on the abdomen and right thigh that had been present for at least seven months.
When inspectors visited the resident's room, they found no EBP signage posted and no Personal Protective Equipment cart available outside the door. These are standard indicators that special infection control measures should be followed when providing care.
The resident confirmed receiving wound care from facility staff and recalled having the wounds for approximately seven months. Medical records showed the resident required wound cleaning and dressing changes three times weekly on specific days, plus additional care as needed.
What Are Enhanced Barrier Precautions?
Enhanced Barrier Precautions represent a critical infection control intervention designed to prevent the spread of multi-drug resistant organisms between nursing home residents. These protocols require healthcare workers to wear gowns and gloves during high-contact care activities with residents who have wounds or indwelling medical devices.
Chronic wounds create an entry point for bacteria and other pathogens. When wounds remain open and non-healing over extended periods, they can harbor resistant organisms that pose transmission risks to other vulnerable residents. The moist environment of wounds provides an ideal breeding ground for bacterial colonization, including potentially dangerous strains like methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE).
Without proper barrier precautions, healthcare workers can inadvertently transfer organisms from wound sites to their clothing, hands, or equipment. These pathogens can then spread to other residents through subsequent care interactions, creating a chain of transmission throughout the facility.
Staff Acknowledge Protocol Failures
When questioned by surveyors, the Licensed Practical Nurse assigned to the resident's care confirmed the resident had wounds and received regular wound care. The nurse acknowledged that residents with wounds typically had EBP in place but stated uncertainty about why this particular resident lacked these protections. The nurse indicated plans to contact the Director of Nursing about the situation.
The facility's Director of Nursing confirmed to inspectors that the resident should have had Enhanced Barrier Precautions implemented as soon as wound care orders were written. The Infection Preventionist similarly acknowledged the protocols should have been in place, explaining that EBP was standard practice for any resident with extensive wound care or open wounds specifically to prevent infection spread.
Facility Policy Requirements
Life Care Center of Reno's own infection control policy, reviewed in June 2024, clearly documented that Enhanced Barrier Precautions must be used for residents with wounds and indwelling medical devices. The policy specified that EBP employed gown and glove use during high-contact resident care activities as a method to reduce transmission of multi-drug resistant organisms.
The gap between written policy and actual practice represents a breakdown in the facility's infection prevention program. When facilities fail to implement their own documented protocols, it suggests deficiencies in staff training, monitoring systems, or both.
Medical Documentation of Chronic Wounds
Physician orders from July 2024 outlined specific wound care procedures for both the abdominal wound and the right medial thigh wound. Treatment protocols included cleaning with normal saline solution, patting dry, applying Xeroform dressing, and covering with clean dry dressings three times weekly.
Wound observation documentation from late July specifically characterized both wounds as chronic and non-healing. Non-healing wounds that persist for months require particularly vigilant infection control measures, as prolonged exposure increases colonization risks with resistant organisms.
Risks to the Broader Resident Population
Nursing home residents represent a particularly vulnerable population for healthcare-associated infections. Many residents have compromised immune systems due to age, underlying medical conditions, or medications. When one resident harbors potentially resistant organisms without proper isolation precautions, the entire facility population faces elevated infection risks.
Healthcare workers moving between residents throughout their shifts can become vectors for pathogen transmission. Proper use of gowns and gloves creates a barrier that prevents this cross-contamination. When these barriers are absent, even routine care activities like repositioning, bathing, or assisting with meals can transfer organisms from surfaces or clothing.
Regulatory Context
The Centers for Medicare & Medicaid Services requires nursing facilities to maintain comprehensive infection prevention and control programs. These programs must include systems to prevent, identify, and manage infections and communicable diseases. Federal regulations mandate that facilities follow their own policies and implement nationally recognized infection control practices.
Enhanced Barrier Precautions became particularly emphasized following guidance from the Centers for Disease Control and Prevention aimed at reducing the spread of resistant organisms in long-term care settings. Facilities are expected to identify residents requiring these precautions and ensure consistent implementation by all staff members providing care.
The violation cited at Life Care Center of Reno was classified as creating minimal harm or potential for actual harm, affecting few residents. However, the failure to implement basic infection control measures for a resident with chronic wounds over an extended period demonstrates a significant oversight in the facility's safety systems.
Families and prospective residents can access the complete inspection report and the facility's plan of correction through the state survey agency or by contacting Life Care Center of Reno directly at 445 W. Holcomb Lane in Reno, Nevada.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Reno from 2024-08-01 including all violations, facility responses, and corrective action plans.
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