Failure to Adhere to Dressing Change and Barrier Precautions Policies
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to treat and prevent pressure ulcers. Specifically, the facility did not adhere to its own policy regarding dressing changes and enhanced barrier precautions. During an observation of a dressing change for a resident with a pressure ulcer on the right heel, it was noted that the dressing was not dated or timed, which is a requirement according to the facility's policy. This lack of documentation made it impossible to determine when the dressing was last applied. Additionally, the registered nurse performing the dressing change did not wear a protective gown, as required by the facility's enhanced barrier precautions policy. The resident in question had a diagnosis of a pressure ulcer on the right heel and diabetes, which necessitated specific wound care orders, including the use of medihoney and gauze. The Director of Nursing confirmed that the dressing should have been dated and that the nurse should have followed the enhanced barrier precautions policy.
Plan Of Correction
1. At time of discovery the nurse was provided education by the DON/NHA on enhanced barrier precautions. The facility cannot retro date the dressing change regardless that the MAR indicates the dressing had been changed the day prior. 2. All other dressings were appropriately dated, and all other enhanced barrier precautions were properly followed. Education was provided by the DON/Designee to the licensed clinical staff on the dating of completed treatments and enhanced barrier precautions. 3. An audit will be conducted for 5 patients per week x 2 weeks then 3 patients weekly for 2 months for patients with dressing changes and or enhanced barrier precautions. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.