Improper Use of Wound Cleanser During Ostomy Care Causes Resident Pain
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to follow professional standards of practice for ostomy care by using a wound cleanser containing sorbitol to clean the peristomal skin of a resident with a colostomy. The resident, who had multiple diagnoses including surgical aftercare following digestive system surgery, pneumonitis, pressure ulcer, and type 2 diabetes, experienced severe pain during the procedure. The LVN used the wound cleanser after the resident's colostomy bag was found leaking, despite facility practice and physician orders indicating that the peristomal area should be cleansed with normal saline or warm water and not with harsh chemicals or alcohol-based products. Interviews with facility staff, including the Director of Nursing, Registered Nurse, and Treatment Nurse, confirmed that wound cleansers are not appropriate for peristomal skin due to the risk of burning and irritation. The resident reported significant pain and burning sensation when the cleanser was applied, describing the spray as smelling strong and feeling like alcohol. Documentation in the resident's medical record and facility guidelines further supported that only gentle cleansing agents should be used for ostomy care, and the use of the wound cleanser was inconsistent with established protocols.