Failure to Follow Professional Standards During Pressure Ulcer Care
Penalty
Summary
A resident admitted with spinal stenosis and stage 4 pressure ulcers to the coccyx and right gluteal fold was observed to receive wound care that did not follow professional standards of practice. Physician orders specified the use of vashe soak, collagen with silver, calcium alginate, kerlix, and super absorbent dressings for the coccyx wound, and vashe soak, collagen powder, calcium alginate, and silicone super absorbent dressing for the right gluteal fold wound. During wound care, the RN applied collagen powder on top of calcium alginate and packed the coccyx wound with her gloved fingers, followed by packing kerlix into the wound, also with her fingers, instead of using an applicator as required. Immediately after treating the coccyx wound, the RN proceeded to treat the right gluteal fold wound without changing gloves, again using her fingers to apply and pack the wound dressing. The RN acknowledged during interview that she did not use an applicator and did not change gloves between wound treatments. The DON also confirmed that the RN should have used an applicator and changed gloves between wounds, and was unable to provide evidence that wound care was provided in accordance with professional standards to promote healing and prevent infection for the resident.