Failure to Provide Proper Pressure Ulcer Care and Infection Control
Penalty
Summary
A resident with multiple complex medical conditions, including quadriplegia, diabetes mellitus, and peripheral vascular disease, was admitted without skin impairments and later assessed as being at moderate risk for skin breakdown. Despite this, the resident developed three new facility-acquired pressure ulcers, including an unstageable pressure ulcer on the right hip. The prescribed treatment for this ulcer was to use a silver alginate dressing, which provides both autolytic debridement and antimicrobial action, but the resident was instead treated with calcium alginate, which lacks antimicrobial properties, for nearly two weeks. This discrepancy was not identified until a survey was conducted. During direct observation of a dressing change, an LPN and the ADON failed to follow proper infection control protocols, including not donning required personal protective equipment and not adhering to enhanced barrier precautions. The LPN also used unclean bandage scissors to cut dressings, reused contaminated instruments, and did not follow the wound care policy for dressing removal and hand hygiene. The ADON confirmed that the treatment was not completed as ordered and that infection control practices were not properly implemented. Facility policies required consistent treatment protocols and individualized care, which were not followed in this instance.