Improper Wound Care Technique Leading to Potential Wound Contamination
Penalty
Summary
The facility failed to provide wound care in a manner that would prevent the possibility of wound infection for two residents with pressure ulcers. During wound care observations, an LPN cleaned the wound beds of both residents from the outer edge toward the inner aspect in a circular motion, rather than from the inner aspect outward as required by facility policy and standard infection control practices. This method of cleaning was repeated multiple times for each resident, and the LPN then dried the wound sites using the same incorrect technique before applying clean dressings. The LPN later confirmed in an interview that she did not clean the wounds correctly and acknowledged that her actions could lead to wound contamination and infection. Resident #1 had a stage IV pressure injury to the sacrum and diagnoses including heart failure and type 2 diabetes mellitus with hyperglycemia, with a moderate cognitive impairment. Resident #4 had a stage 3 pressure ulcer of the sacral region and diagnoses of essential hypertension and type 2 diabetes mellitus, and was unable to complete a cognitive interview. Both residents had physician orders for specific wound care regimens. The facility's infection preventionist and DON confirmed that the wounds were not cleaned according to policy, and that the improper technique could result in contamination of the wounds.