Failure to Provide Timely Pressure Ulcer Care and Maintain Infection Control
Penalty
Summary
A deficiency occurred when staff failed to provide timely incontinence care to a resident with a known pressure injury. The resident, who was paraplegic, cognitively intact, and always incontinent of bowel, was left sitting in feces in a common area after his room was sprayed for pests. Staff were aware of the resident's soiled condition but did not know where to take him for care, as his room was unavailable and there were no empty rooms on the unit. The resident remained in this state for over an hour, and when finally assisted, was found to have feces on and between his buttocks, extending to the area of his pressure injury, with reddened skin observed. The care plan for this resident required incontinence care after each episode, and facility policy stated that skin should be cleaned promptly after incontinence, but these interventions were not implemented as required. Another deficiency was identified in the infection prevention and control practices during wound care for a resident with a pressure injury on the right heel. During wound care, an RN failed to clean the overbed table or use a barrier before placing wound care supplies on it. The RN also did not perform hand hygiene after removing the resident's shoe and before beginning wound care. These lapses in infection control created a potential for contamination of the wound site. The facility's policy required cleaning the bedside stand and establishing a clean field before placing supplies, as well as proper hand hygiene, but these steps were not followed. Both residents involved had significant risk factors for pressure injuries and required specific interventions as outlined in their care plans and physician orders. The first resident had a history of C. difficile infection, was dependent on staff for all mobility and toileting, and had a stage 3 pressure injury that worsened over the week. The second resident had a right heel pressure injury and a recent hip fracture, requiring pressure-relieving devices and careful wound care. In both cases, staff actions and inactions directly led to failures in pressure ulcer care and infection prevention.