Failure to Follow Wound Care Orders and Improper Use of Plastic Bags Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary standards of care and services for wound and skin care management for a cognitively intact female resident with multiple comorbidities, including CHF, diabetes, hypertension, lymphedema, and cellulitis. The resident developed new venous wounds on her lower legs, which required daily dressing changes and specific wound care as ordered by the physician. Despite these orders, a nurse placed black plastic trash bags over the resident's lower legs for over two days to manage copious drainage, without physician authorization. The plastic bags were not removed or reported to the next shift, and the resident's condition was not communicated to the physician despite a significant change in wound drainage and frequency of dressing changes. When the wound nurse discovered the plastic bags, the resident's dressings were heavily saturated, and the wounds had significantly deteriorated, with the skin sliding off and increased pain reported. Documentation showed that the resident did not have a history of refusing care, and interviews with staff confirmed that the resident wanted to heal her wounds. There was also a lack of timely wound assessments and incomplete documentation regarding treatment refusals and physician notifications. The facility's wound nurse and DON confirmed that the use of plastic bags was not an acceptable practice and that physician orders were not followed. The resident subsequently developed cellulitis and sepsis, requiring hospitalization for septic shock and intravenous antibiotics. She was later discharged back to the facility on hospice care and died shortly thereafter. The investigation revealed that the nurse responsible for the improper treatment received only verbal education, and there was no evidence of a thorough incident or accident report being completed. The deficient practice directly contributed to the resident's rapid decline, hospitalization, and death.