Unlicensed Staff Performed Wound Treatment Using Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s wound was treated by a licensed nurse, as required by facility policy. During care, Resident 1 sustained a skin tear, described as an acute, traumatic wound where the top layers of skin separate from the underlying tissue. Certified Nursing Assistant (CNA) 2 reported that after the skin tear occurred, CNA 3 went to the treatment nurse and obtained triple antibiotic ointment, a pad to clean the wound, and a bandage. CNA 2 stated that CNA 3 cleaned Resident 1’s skin tear, applied the triple antibiotic ointment, and then placed the bandage on the wound. The Director of Nursing (DON) stated that CNAs are not allowed to perform wound treatments. Review of Resident 1’s Special Problems documentation dated 12/21/25 showed an entry indicating that after accidentally hitting the resident against the side rail, CNA 3 went to get a bandage and some antibiotic ointment and applied it to the resident, with the note signed by CNA 3. In a separate interview, CNA 3 confirmed that Resident 1 received a skin tear during care, that she informed the treatment nurse, and that the treatment nurse gave her ointment and a bandage, which she then applied to the resident’s skin tear. Review of the facility’s Medication Administration Schedule policy, revised 10/19/22, indicated that medications are to be administered only by persons legally authorized to do so and prepared only by licensed nurses, pharmacy, or other personnel authorized by state regulations, which was not followed in this instance.
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