Lack of Staff Competency and Education for Wound Vac Care
Penalty
Summary
Nurses and nurse aides at the facility failed to demonstrate appropriate competencies and did not receive necessary education to care for a resident with a wound vacuum (wound vac) following a hip replacement. The resident, who was cognitively intact, required the wound vac due to drainage at the surgical site. However, there was a period when the wound vac was not in use because it became full and staff were unsure how to manage it, leading to its discontinuation. The resident did not have a care plan, physician orders, or evidence of monitoring for the wound vac for 22 days after its placement. Review of staff education files revealed that none of the three licensed nurses who cared for the resident had received wound vac training or competency assessments. The Director of Nursing confirmed that no education or competencies were provided for wound vacs, and the Nurse Educator was unfamiliar with the facility's own education and competency documentation referenced in the facility assessment. As a result of these deficiencies, the resident developed an infection at the surgical site, requiring hospitalization and two additional surgical interventions.