Failure to Change Gloves During Pressure Ulcer Dressing Change
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A registered nurse failed to follow the facility's clean dressing change policy during the treatment of a resident with a stage III pressure ulcer on the left heel. The nurse removed the resident's soiled dressing while wearing gloves, but did not change gloves before cleansing the wound with gauze wet with normal saline. The same soiled gloves were used for both removing the dressing and cleansing the wound, contrary to the facility's policy, which requires glove removal and hand hygiene after dressing removal and before wound cleansing. The resident was observed sitting in a wheelchair at the time of the dressing change, and the wound was described as an open area approximately the size of a dime with a small amount of drainage.