Lafayette Pointe Nursing & Rehab Ctr

Provide and implement an infection prevention and control program.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review the facility failed to maintain enhanced barrier precautions (EBP) during wound care for a resident with a pressure injury.

This deficient practice affected one resident (Resident #35) out of three residents reviewed for infection control.

The facility census was 58.Findings Include:Review of Resident #35's medical record revealed an admission date of 04/21/23 with diagnoses including but not limited to type two diabetes, Peripheral Vascular Disease (PVD), edema, and depression.Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition, had an unhealed stage three pressure injury and surgical wounds were present.Review of Resident #35's physician orders revealed an order dated 10/26/25 to cleanse left outer heel with normal saline (NS) and apply a layer of hydrogel and cover with an abdominal dressing and gauze daily and as needed (PRN) for wound care, and an order dated 11/18/25 for Enhanced Barrier Precautions (EBP) for wounds.An observation was conducted on 11/19/25 from 1:32 P.M. to 1:45 P.M. of Licensed Practical Nurse (LPN) #220 completing wound care and dressing change to Resident #35's left outer heel pressure injury. Resident #35's door had a sign indicating Resident #35 was on EBP for wound care, and staff were to wear a gown and gloves while completing the task. LPN #220 entered the room, washed hands and put gloves on prior to removing the soiled dressing and disposing of the dressing in the trashcan. LPN #220 removed the soiled gloves, washed hands and placed clean gloves on to cleanse the left outer heel pressure injury with normal saline and gauze. LPN #220 placed the used gauze in the trashcan, washed hands and placed a clean pair of gloves on to place the medication and clean dressing in place. LPN #220 completed the dressing change, removed the towel barrier and placed the dressing packaging in the trashcan, washed hands and exited the room. LPN #220 did not place a gown on during wound care and dressing change for Resident #35.An interview on 11/19/25 at 1:45 P.M. with LPN #220 confirmed a gown was not worn during the wound care and dressing change for Resident #35 requiring EBP due to having wounds. LPN #220 also confirmed the EBP sign located on Resident #35's door indicated the use of a gown during high contact resident care activities, which included wound care.Review of the facility policy titled Standard and Transmission-Based Precautions dated 03/24/24 revealed Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.This deficiency represents non-compliance investigated under Complaint Number 2644903.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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