Inappropriate Pressure Ulcer Treatment Provided
Penalty
Summary
A deficiency was identified when a wound nurse failed to provide appropriate treatment for a resident with an existing pressure ulcer. During a treatment observation, the nurse applied skin prep directly to an open pressure ulcer on the resident's right hip, despite skin prep being intended only for intact skin and not for open wounds. The nurse had removed a bandage with dried bloody drainage and noted the wound was red and open, then proceeded to clean the wound with normal saline, pat it dry, and apply the skin prep before covering it with a foam bandage. The nurse indicated this was the first time the wound was open. The resident involved had multiple diagnoses, including stroke, dementia, protein malnutrition, psychotic disorder, osteoporosis, and high blood pressure, and was not cognitively intact for daily decision making. The care plan required treatments to be administered as ordered. Physician orders specified different treatments for the left and right hips, with the right hip to be cleaned, dried, have barrier film applied, and then covered. However, the nurse applied skin prep to the open right hip wound, contrary to the order and standard practice. Interviews confirmed the wound was now a Stage 2 pressure ulcer and that skin prep should not have been used on the open area.