Failure in Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. Resident 16, who had chronic diastolic congestive heart failure, chronic respiratory failure, and chronic kidney disease, was transferred to the hospital with a sacral wound that was not properly evaluated or documented according to facility policy. The facility's policy required weekly wound evaluations, but these were not consistently completed, and the Director of Nursing confirmed the lack of documentation. Additionally, Resident 16 refused wound care on two occasions before being transferred to the hospital, where the wound was found to be in a moist environment and described as a pressure ulcer. Resident 325, who had stage two chronic kidney disease and diabetes mellitus type II, was admitted with a stage 3 pressure ulcer to the sacrum. During a dressing change observation, Employee 9 did not adhere to enhanced barrier precautions by failing to wear a gown and not performing proper hand hygiene. Employee 9 touched unclean surfaces and handled a marker without changing gloves or performing hand hygiene before accessing the resident's wound dressing. The Director of Nursing confirmed that Employee 9 did not follow the facility's expectations for infection control practices. The facility's failure to adhere to its own policies and procedures for wound management and infection control led to deficiencies in the care provided to Residents 16 and 325. The lack of consistent wound evaluations and improper infection control practices during dressing changes contributed to the facility's inability to promote healing and prevent infection for these residents.
Plan Of Correction
Resident 16 has been discharged from the facility. Resident 325 had a wound evaluation completed. A comprehensive review of current residents with pressure ulcers will be conducted to ensure that weekly wound evaluations are completed and Enhanced Barrier Precautions are followed as per policy. The facility will take the further steps to ensure that the problem does not re-occur by in-servicing licensed nursing on FTag 686 as well as IC308 Enhanced Barrier Precautions. Compliance will be monitored by the Director of Nursing/Designee using the Pressure Ulcer Wound Audit and Enhanced Barrier Audit to review 5 residents weekly x 3 weeks and monthly x 2 months, with audit results being forwarded to the QAA committee to determine the need for further follow up/monitoring.