Incorrect Wound Vac Application Led to Worsening Pressure Injury
Penalty
Summary
A resident with a stage 4 pressure injury on the right hip and a wound vac was admitted to the facility with additional diagnoses of cellulitis and paraplegia. The resident required assistance from one to two staff for repositioning and had intact cognition. The facility's policy required that residents with pressure ulcers receive necessary treatment and services to promote healing and prevent infection, using interventions based on current standards and provider orders. The resident's wound vac dressing was applied incorrectly by a registered nurse, as the base drape layer was not placed around the wound during the dressing change. This omission led to skin erosion, irritation, and an increase in the size of the wound, as confirmed by the wound nurse practitioner. The wound vac could not be reapplied due to the skin condition, and the resident required a different type of dressing while the skin healed. The resident had previously reported concerns about the wound vac dressing not being done correctly, and the facility's investigation confirmed the error was due to lack of education for the nurse who performed the dressing change. Interviews with staff revealed that the nurse responsible for the incorrect dressing application was not aware of the mistake until informed by the resident and did not receive education or follow-up until several days after the incident. Other nursing staff also indicated they had not received prior education on wound vacs related to the incident. The documentation showed that the wound worsened following the incorrect application, and the resident expressed concerns that the issue was delaying discharge and affecting their emotional well-being.