Improper Wound Cleansing Technique Leading to Cross-Contamination Risk
Penalty
Summary
The facility failed to ensure that wound care was provided in accordance with professional standards of practice and the resident's person-centered care plan for one resident with a venous stasis ulcer. During an observed wound care procedure, the wound care nurse cleansed the resident's wound using a folded gauze soaked in wound cleanser, scrubbing the center of the wound in an up and down motion, then moving to the outside, and then returning to the center, repeating this process for approximately 1-2 minutes. The nurse continued to use the same blood-soaked gauze to clean both the outside and center of the wound multiple times, rather than discarding it after it became contaminated. Interviews with the wound care nurse, ADON, and DON confirmed that the proper technique should have involved cleansing from the inner part of the wound to the outer area (clean to dirty), discarding the dirty gauze after use, and not reusing contaminated gauze. The nurse acknowledged that her actions could have caused cross-contamination and introduced bacteria into the wound. The resident involved had multiple diagnoses, including peripheral vascular disease, hemiplegia, hemiparesis, type 2 diabetes with skin ulcer, and chronic venous hypertension with ulcer, and was cognitively intact at the time of the incident.