Cross Contamination During Stage 4 Pressure Ulcer Dressing Change
Penalty
Summary
Failure to prevent cross contamination during pressure ulcer care occurred during treatment of a resident with a Stage 4 sacral pressure ulcer. The resident was documented on the MDS as severely cognitively impaired and dependent on staff for oral hygiene, bathing, dressing, toileting, personal hygiene, bed mobility, and transfers. The EMR listed medical diagnoses including muscle wasting and atrophy, wedge compression fracture of the second lumbar vertebra, macular degeneration, sacral pressure ulcer, and abnormalities of gait and mobility. The resident’s pressure ulcer risk assessment identified the resident as high risk for pressure ulcers, and the wound evaluation summary documented a Stage 4 sacral pressure ulcer on the sacrum that was an open ulceration cluster with moderate serous drainage and noted as “Not at Goal.” Physician orders directed cleansing the sacral area with wound wash, applying collagen powder, packing the wound with gauze soaked in quarter-strength bleach solution, and covering with an absorbent pad secured with retention tape. During observed wound care, an LPN/wound nurse and a CNA completed dressing care at the bedside. While the LPN prepared the wound dressings on the bedside table, the table was pushed into the resident’s privacy curtain, causing the curtain to directly touch the open top of the bleach solution bottle, the entire length and part of the sides of the bedside table, and the dressing supplies. The LPN did not disinfect her scissors after removing them from her scrub top pocket and before cutting the dressings, despite facility policy requiring scissors used for dressing changes to be disinfected prior to and after use. The LPN then placed the contaminated dressing directly on the resident’s Stage 4 sacral pressure ulcer, which was described as having a dark red center, white edges, dark red periwound, and moderate serous drainage. The LPN later confirmed she had cross contaminated the wound supplies by allowing the privacy curtain to touch them and by not disinfecting the scissors after they had been returned to her pocket.
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