Failure to Maintain Clean, Dry Conditions During Sacral Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with its own pressure injury prevention policy and professional standards of practice for a resident with a Stage 4 sacral pressure ulcer. The facility’s policy required residents to be kept clean and dry and to receive appropriate incontinent care as part of pressure injury prevention and treatment. The resident had multiple significant diagnoses, including multiple sclerosis, a Stage 4 sacral pressure ulcer, altered mental status, and hemiplegia/hemiparesis, and was documented as severely cognitively impaired and dependent on staff for toileting and personal hygiene. Physician orders and the resident’s care plan directed that the sacral area be cleaned with wound cleanser, Ioplex applied, and the area covered with a super absorbent dressing three times weekly and as needed if soiled. During an observed wound care treatment, the treatment nurse removed a saturated dressing from the resident’s sacral area and performed the ordered wound care while leaving a soiled brief in place. After completing the wound care and securing the new dressing, the nurse repositioned and secured the same soiled brief on the resident and replaced the bed linens without changing the brief. The treatment nurse acknowledged during interview that the brief was soiled during the wound care treatment. The DON later stated in interview that the soiled brief should have been changed prior to starting wound care and should not have been left on the resident after the wound care was completed.
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