Failure to Cleanse Fecal Matter from Pressure Ulcer During Wound Care
Penalty
Summary
During wound care for a resident with a sacral pressure ulcer, staff failed to thoroughly cleanse the area around the wound, leaving fecal matter at the exterior border. The facility's policy and the resident's wound care orders required cleansing the wound and surrounding area with a specified solution and patting it dry with gauze. Observation showed that the wound nurse and CNA performed wound care without removing a round ball of light brown fecal matter present in the upper gluteal cleft at the exterior border of the wound. After completing the dressing change, the staff replaced the resident's adult brief and covered her without addressing the fecal matter. The wound nurse later confirmed that the fecal matter should have been cleansed from the wound area.