Failure to Follow Ordered Pressure Ulcer Treatment and Aseptic Technique
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer treatment as ordered for a resident with a stage 4 sacral pressure ulcer and paraplegia. The resident’s MDS showed intact cognition with a BIMS score of 15 and documented diagnoses including paraplegia and a stage 4 sacral pressure ulcer. Wound clinic orders dated 12/18/25 directed staff to apply acetic acid–dampened gauze to the wound base and surrounding skin and leave it in place for 10–15 minutes, then remove it, apply Calmoseptine around the left buttock wound, apply Melgisorb Ag (calcium alginate) to the wound base, pat dry, allow 30 minutes of air time, and then return to place an ABD pad secured with Medipore tape. During an observed wound treatment, the RN reviewed the order on the computer, performed hand hygiene, donned gloves, and opened gauze, placing half of it on supplies without a barrier. The RN touched the computer with gloved hands, dampened gauze with acetic acid, and cleansed the wound but did not leave the acetic acid–dampened gauze in place for the ordered 10–15 minutes. The resident was rolled onto her back without a barrier and the area was left uncovered while the RN applied pain cream to the resident’s shoulder. Later, the RN again touched the computer and then donned gloves without hand hygiene, used a gloved finger to obtain and apply Calmoseptine to two sacral wounds, and with the same gloved hand handled and cut Melgisorb Ag and placed it on the wound base. The RN then changed gloves without performing hand hygiene, applied an ABD pad, secured it with tape, and documented completion of the treatment. The DON acknowledged that the treatment was not completed per the physician’s orders.
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