Failure to Provide Proper Wound Care and Prevention of Skin Breakdown
Penalty
Summary
The facility failed to provide wound care in accordance with professional standards of practice and physician's orders for two residents with pressure ulcers. Observations revealed that a Licensed Practical Nurse (LPN) cleansed wounds by wiping back and forth across the wound bed multiple times with the same gauze, rather than discarding it after a single pass, and did not pat the wounds dry before applying prescribed treatments and dressings. This was observed during wound care for both the hip and sacral wounds of one resident, and the sacral wound of another resident. The facility's own policy required drying the skin by patting with a soft gauze, and physician orders specifically instructed to pat dry the wounds prior to dressing application. Additionally, both residents were found to be wearing two briefs at the time of care, a practice acknowledged by staff as contrary to their training and facility policy, and known to increase the risk of skin breakdown and infection. Interviews with staff, including the LPN and Director of Nursing (DON), confirmed that wounds were not dried as required and that double briefing should not occur. Both residents involved were severely cognitively impaired and had a history of pressure ulcers, as documented in their medical records.