Failure to Prevent Cross Contamination and Implement Wound Care Orders
Penalty
Summary
The facility failed to prevent cross contamination during wound care and did not implement physician-ordered pressure ulcer treatments for one resident with multiple wounds. Specifically, a registered nurse (RN) did not perform hand hygiene or change gloves after cleansing a resident's sacral wound and before applying a clean dressing, contrary to the facility's wound care policy and standard infection control practices. The RN believed that hand hygiene and glove changes were only necessary after removing soiled dressings, not after wound cleansing. This lapse was observed during a wound treatment procedure and confirmed by the RN involved. Additionally, the facility did not ensure that all physician orders for wound care were entered into the resident's electronic medical record (EMR). A wound physician had ordered a skin protectant for the resident's heels, but this order was not entered into the EMR prior to a certain date, resulting in the treatment not being administered as prescribed. The resident had a history of an unstageable pressure ulcer of the coccyx, a deep tissue injury to the right heel, and a stage four sacral pressure ulcer. Staff interviews and record reviews confirmed that the required interventions were not consistently implemented according to physician orders and facility policy.