Failure to Ensure Proper Wound Vac Management and Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including quadriplegia, diabetes, and a history of osteomyelitis, did not receive appropriate care and services to prevent pressure injuries and promote healing. The resident had a wound vac (negative pressure wound therapy) placed by a wound provider, with orders for dressing changes per protocol. On one occasion, staff reported to the Director of Nursing (DON) that the wound vac dressing was not adhered properly, but the DON did not assess the dressing or ensure the wound vac was functioning as intended. Certified Nursing Assistants (CNAs) observed that the dressing was bunched up and not suctioning, and communicated this to the DON, who stated the dressing was fine and did not further assess the situation. Subsequent nursing assessments documented worsening maceration and a deteriorating wound condition, with the wound vac dressing being replaced and noted to be running correctly at one point. However, later documentation and interviews revealed that the wound vac dressing was not intact, the foam was not suctioning, and there was a strong odor at the wound site. The resident developed a low-grade fever and redness, and alternative wound care was provided after the wound vac was removed. Staff interviews indicated that some nurses were uncomfortable with wound vac dressing changes, and alternative dressing orders were provided for such situations. Despite these measures, there was a lack of consistent assessment and intervention when concerns about the wound vac's function were raised. The facility's policies required ongoing review of interventions and adherence to clinical guidelines for negative pressure wound therapy. However, the failure to promptly assess and address the malfunctioning wound vac, as well as the lack of comprehensive staff education on wound vac management, contributed to the resident not receiving the necessary care to prevent further deterioration of the pressure injury.