Failure to Provide Proper Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for two residents with pressure ulcers. One resident, who was severely cognitively impaired and had multiple stage IV and unstageable pressure ulcers upon admission, did not consistently receive wound care as ordered. Observations revealed that the resident's wounds were left uncovered for extended periods, and wound care supplies, including soiled dressings, were improperly disposed of in the resident's bathroom. The resident reported discomfort in the affected area, and staff interviews confirmed that dressings were not always checked or replaced as required. During wound care observations, the ADON failed to follow infection control protocols, including not changing gloves or performing hand hygiene between wounds, and not donning appropriate PPE. PPE was not available at the resident's door, and there was no PPE hanger present. The ADON acknowledged these lapses, stating that her actions increased the resident's risk for infection. The ADON also admitted that there was no formal process for wound monitoring beyond weekly assessments and that communication between nursing leadership regarding wound care was ineffective. The DON confirmed that staff were expected to follow evidence-based practices, including changing gloves and using PPE during wound care, but acknowledged that these expectations were not consistently met. The DON also stated that there was no formal process in place to ensure ongoing wound monitoring for healing or deterioration, aside from weekly assessments and monthly Quality Assurance meetings. Facility policies required daily monitoring of pressure ulcers, proper use of PPE, and documentation of interventions, but these were not consistently implemented, leading to deficiencies in pressure ulcer care and infection control.