Failure to Implement Proper Pressure Ulcer Prevention and Wound Care Protocols
Penalty
Summary
The facility failed to implement preventive measures and appropriate treatment modalities for skin impairment in three residents reviewed for wound care prevention management. Observations revealed that residents using low air loss (LAL) mattresses had multiple layers of linens, including cloth pads and flat sheets, contrary to manufacturer recommendations that only a flat sheet should be used. Both the Director of Nursing and the Wound Care Nurse acknowledged that the use of additional linens impedes the effectiveness of the LAL mattress. Staff members, including agency CNAs, were unaware of the correct linen protocol for LAL mattresses, and the facility was unable to provide a policy regarding this requirement. In addition to improper use of LAL mattresses, deficiencies were observed in wound care and incontinence management. For one resident, the Wound Care Nurse did not complete a wound assessment after the development of a moisture-associated skin disorder (MASD), nor was the care plan updated to reflect the new condition. During incontinence care, a CNA failed to change gloves between cleaning soiled areas and applying a clean brief, and did not perform hand hygiene before donning new gloves. The prescribed application of zinc oxide ointment or barrier cream after incontinence care was not consistently followed as indicated in the care plan. Another resident was found with a sacral wound that was uncovered, and the Wound Care Nurse was not notified when the dressing was removed. The LAL mattress pump was found on the floor due to the absence of a footboard, which was not addressed by the building manager. The facility's policies on pressure injury prevention, non-sterile dressing changes, and LAL mattress management were not consistently implemented, contributing to the deficiencies in wound care and skin integrity management.