Failure to Follow Wound Care Orders and Hand Hygiene Protocols During Pressure Ulcer Treatment
Penalty
Summary
A resident with a stage 4 pressure ulcer on the left hip was admitted to the facility and had specific physician orders for wound care, including cleaning with wound cleanser, applying Hydrofera blue into the wound, and covering with bordered gauze, to be changed three times weekly and as needed. During an observed dressing change, an LPN did not follow the current physician orders and instead packed the wound with Theraform blue soaked in Dakin's solution, contrary to the updated orders which no longer required Dakin's solution. The LPN also failed to perform hand hygiene at multiple required points during the dressing change, as outlined in the facility's policy for clean dressing changes. Interviews with the LPN, the nurse practitioner, and the nursing home administrator confirmed that the wound care provided did not align with the most recent provider orders and that hand hygiene standards were not met. The nurse practitioner clarified that Dakin's solution was no longer indicated for the resident's wound, and the administrator stated that staff are expected to follow provider orders and facility policies regarding wound care and hand hygiene. These failures were identified through observation, interview, and record review.