Sterile Technique Breach During Pressure Ulcer Dressing Change
Penalty
Summary
A deficiency occurred when an LPN failed to maintain sterile technique during a dressing change for a resident with a stage 4 sacrococcygeal pressure ulcer with tunneling. After cleansing the wound, the LPN retrieved a piece of silver alginate dressing that had been resting on the non-sterile outer wrapper of the product packaging and inserted it into the tunneling wound using a sterile cotton-tipped applicator. The LPN acknowledged that the outer surface of the packaging was not sterile and that this action could have contaminated the dressing. Physician's orders required daily cleansing with Vashe solution, drying, and application of silver alginate to the wound bed. Facility policy directed that dressings be opened without contaminating and kept within the open packet or placed directly on top of a barrier.