Failure to Provide Proper Wound Care and Hygiene Prior to Dressing Change
Penalty
Summary
A deficiency occurred when wound care for a resident with a stage 4 sacral pressure ulcer was not performed in accordance with facility policy and infection control standards. During an observed wound care procedure, LPNs removed a wound vacuum and dressing from the resident while the resident's bed linens and brief were heavily soiled with yellow and brown urine. Peri-care was not performed prior to the wound care, and the LPN acknowledged not noticing the soiled condition until after the procedure was completed. The wound care nurse confirmed that wound care was initiated despite the resident being visibly soiled and that peri-care is typically provided beforehand with CNA assistance. The resident, who has severe cognitive impairment, reported being changed only once at night and remaining wet for long periods, with staff not checking on her during the night. The Director of Nursing confirmed that peri-care should have been completed before wound care and that failure to do so could lead to contamination and further skin breakdown. Facility policy requires dressing changes to be performed as ordered and infection control policies to be followed to prevent contamination in individuals with pressure ulcers.