Failure in Pressure Ulcer Care and Infection Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent infection for a resident with a stage three pressure ulcer on the sacrum. During a wound dressing observation, a Licensed Practical Nurse (LPN) was seen preparing the resident for a dressing change. After repositioning the resident, the LPN noticed a bowel movement and cleaned it up. However, the LPN did not perform hand hygiene with soap and water after cleaning the bowel movement and before starting the dressing change, opting instead to use an alcohol-based hand rub. Additionally, the dressing on the resident's wound was not dated. The LPN was also observed retrieving a marker from her pocket with bare hands to label the new dressing, which was not considered a clean area. This was confirmed during a staff interview, where it was acknowledged that the LPN should have performed hand hygiene with soap and water and that the pocket was not a clean surface. Furthermore, it was confirmed that wound dressings should be labeled with the date, time, and initials when applied.
Plan Of Correction
Resident 37 has been evaluated for infection. No signs or symptoms of wound infection noted at this time. All residents with wounds will be evaluated for symptoms of infection. Residents with symptoms of infection will be assessed by an RN and the physician or CRNP will be notified. Treatment application policy will be updated to include washing hands versus using alcohol-based hand sanitizer when hands are visibly soiled. Clarification of wound dressing date has been updated in treatment application policy to include dating dressing during equipment set up prior to removal of old dressing. All licensed staff will be educated on updated policy to ensure prevention of infection. A QA tool has been developed to review 10% of treatment applications weekly to ensure policy compliance and prevention of infection. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.