Failure to Maintain Pressure Ulcer Dressing and Adhere to Infection Control Practices
Penalty
Summary
A resident with multiple complex medical conditions, including stage IV sacral pressure ulcer, Alzheimer's disease, vascular dementia, and a syndrome causing frequent bowel movements, was admitted from an acute care hospital and was receiving hospice care. Provider orders specified daily wound care for the stage IV pressure ulcer, including cleansing and application of topical medications, with instructions to keep the dressing clean, dry, and intact. The resident's care plan also emphasized the need for wound care per order, monitoring and replacing dressings as needed, and reporting any issues with the dressing to nursing staff. During observation, the resident was found in bed with a large, uncovered sacral wound exposing muscle, tendon, and bone. Interviews with staff revealed that the wound had been left uncovered for an extended period, and there was confusion and lack of communication among CNAs, hospice aides, and nursing staff regarding responsibility for checking and reporting on the wound's status. The hospice aide reported that the wound was already uncovered during morning care and was unable to locate nursing staff to report the issue. CNAs admitted to not checking the sacral area during rounds and not reporting the uncovered wound, despite being trained to do so. Additionally, during incontinent care, a CNA failed to perform proper hand hygiene and glove changes when moving from contaminated to clean areas, contrary to facility policy and infection control standards. Facility leadership, including the ADON, DON, and Administrator, confirmed that their expectation was for wounds to be covered at all times and for staff to follow hand hygiene protocols, but these standards were not met in this instance. Facility policies reviewed also required adherence to hand hygiene and pressure injury prevention practices, which were not followed in the care of this resident.