Resident Privacy Compromised During Wound Care
Penalty
Summary
A male resident with chronic venous ulcers, cellulitis, and significant skin issues to both lower extremities was observed having his wound dressing changed in a public area of the facility. The resident, who had recently returned from a whirlpool treatment to provide moisture to his lower legs, was initially positioned in his wheelchair in the hallway. A registered nurse began to perform wound care at the doorway of the nurse's station, in view of others, before being instructed by the Director of Nursing to move the resident to his room. The nurse stated that the resident's room was too small to perform the dressing change, but ultimately directed the resident to self-propel to his room, where the dressing change continued with the nurse kneeling in the hallway and the resident just inside his doorway. During the dressing change, there were no protective chucks placed under the resident's feet, despite the presence of dry, flaky, and peeling skin, as well as visible blood between the toes and on the tops of the feet. The dressing itself showed spots of fresh blood. Interviews with facility staff confirmed that wound care should not have been performed in a public area, as this compromised the resident's privacy and dignity. The incident was directly observed by surveyors and corroborated by staff interviews and record review.