Failure to Maintain Dry Wound Dressing Prior to Medical Appointment
Penalty
Summary
A resident with a history of an unspecified wound on the left foot, left heel infection, and cognitive communication deficit was admitted to the facility. Physician's orders specified that the resident's wound dressing should not get wet during showers or baths, and that the area should be covered with a cast cover or plastic bag to prevent water exposure. On the day of a scheduled wound care appointment, the resident was assisted with a shower by a CNA, who reported wrapping the resident's left leg/foot in plastic. However, the resident's bandages were found to be wet upon arrival at the wound care appointment, as confirmed by a family member. The physician's orders also noted that the dressing had been soaked previously and reiterated the importance of keeping the dressing dry. Observation of wound care by an LVN later revealed that the dressings were dry and intact at that time, but the resident had open areas on the top of the foot and heel, with pain reported during the procedure. The DON confirmed in an interview that a wet dressing could lead to tissue breakdown and that the nurse should have changed the dressing if it was wet. The facility failed to ensure that the resident received care in accordance with professional standards and the comprehensive care plan, as the resident was sent to a medical appointment with a wet wound dressing, contrary to physician's orders.