Failure to Follow Wound Care Orders and Infection Control Procedures for Pressure Ulcer
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident with a history of multiple pressure ulcers, including a sacral wound infection. Upon re-admission, the resident had specific wound care orders, including cleansing with wound cleanser, applying medicated foam and Dakin's solution-moistened gauze as packing into the wound and undermining/tunneling, and securing with bordered gauze. Observations revealed that these orders were not consistently followed, as wound packing was omitted during dressing changes, despite the orders specifying its use. The resident was also observed lying on their back, contrary to discharge instructions to offload pressure from the wound, and reported difficulty maintaining side positioning due to discomfort and lymphedema in the left leg. During wound care observation, a registered nurse was seen donning gloves from their uniform pocket without performing hand hygiene between glove changes, and using supplies from their uniform, which is considered unclean. The nurse did not apply packing to the wound bed as ordered, and there was confusion regarding the current wound care orders. The resident expressed awareness of the need for packing and frequent dressing changes due to stool contamination, but the nurse denied that packing was part of the current orders. The wound dressing was also observed to be soiled with stool, and the dressing technique covered the resident's anus, potentially increasing the risk of further contamination. Interviews with nursing staff and management confirmed that the wound care orders included packing with Dakin's solution and that this should be done with every dressing change. Staff acknowledged the challenges posed by the resident's anatomy and frequent incontinence, which contributed to wound contamination. Infection control breaches were noted during wound care, including improper glove use and lack of hand hygiene, and staff did not demonstrate awareness of these issues during the surveyor's observation.