Failure to Follow Wound Care Protocol and Infection Control During Pressure Ulcer Treatment
Penalty
Summary
A resident with a stage 4 pressure ulcer to the sacral region was readmitted to the facility with physician orders for specific wound care, including cleaning with vashe wash, packing with alginate AG, and applying a collagen sheet daily and as needed. During a dressing change observed by a surveyor, a registered nurse failed to follow infection control procedures by not removing soiled gloves or performing hand hygiene after removing the soiled dressing, and then used the same gloves to apply the clean dressing. Additionally, the nurse applied a collagen sheet containing silver, which was not the type ordered by the physician. Staff interviews confirmed that the nurse did not change gloves or perform hand hygiene as required by facility policy and professional standards of practice. The Director of Nursing Services also acknowledged that the physician's order for the wound dressing was not followed and that proper infection control procedures were not observed during the dressing change.