Failure to Prevent Cross-Contamination and Ensure Wound Care Compliance
Penalty
Summary
The facility failed to prevent cross-contamination during wound care for a resident with severe cognitive impairment and significant mobility limitations. The resident had physician orders for daily wound care to the right ankle arterial wounds, including specific instructions for cleaning and dressing the wounds. Observations revealed that a nurse used the same piece of gauze to cleanse multiple open wounds on the resident's ankle, wiping both the wounds and surrounding skin, which constitutes improper wound care technique and risk of cross-contamination. Additionally, the resident's dressings were not labeled or dated as required. Record review and staff interviews indicated that contract nurses were assigned to the resident for several days, during which time wound care was not consistently performed as ordered. The resident was later found in a hospital with maggots present in the wound, and the dressing was adhered to the skin, suggesting it had not been changed for an extended period. Facility staff confirmed that wound care documentation was signed off as completed, even when the dressing had not been changed, and that there was no system in place to ensure treatments were actually performed or monitored. Further interviews with facility staff, including the DON and wound care nurses, revealed a lack of oversight and auditing of wound care practices, especially during the absence of the primary wound nurse. Staff reported that contract nurses often did not perform wound care, and there was no process to verify that dressings were changed or that physician orders were followed. The facility relied on reviewing treatment records for compliance but did not visually inspect wounds or dressings to confirm care was provided as ordered.