Failure to Implement and Maintain Pressure Ulcer Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate interventions to heal and protect pressure ulcers for a resident with multiple medical conditions, including moderate protein-calorie malnutrition, dementia, cerebral infarction, and Parkinson's disease. The resident was dependent on staff for all activities of daily living and mobility, and was identified as being at risk for pressure ulcers, with existing Stage 1, Stage 2, and Stage 3 ulcers. The care plan and wound care orders specified the use of skin protectant, Mepilex, ABD pads wrapped with InterDry, and bordered gauze dressings for the resident's finger wounds. Despite these orders, multiple observations revealed that the resident did not have the required dressings or ABD pad with InterDry in place on either hand. Instead, DermaSaver Finger Separators were found directly against the resident's untreated, uncovered wounds. During wound care, an LPN failed to change gloves or perform hand hygiene after handling contaminated DermaSaver Finger Separators and before treating the wounds, which is inconsistent with infection control protocols. Interviews with staff confirmed that the DermaSaver Finger Separators were not effective and were not supposed to be used at that time, and that the required dressings were not consistently applied as ordered. Further review and interviews established that the wound care orders from the APRN required bordered gauze dressings for both the left and right 5th finger wounds, but staff did not consistently apply these dressings, particularly on the right hand. The DON confirmed that a border dressing should have been applied to the right-hand 5th digit per the APRN's order. These failures resulted in the resident not receiving the prescribed wound care interventions to promote healing and prevent further injury.