Improper Wound Care and Hand Hygiene for Resident With Unstageable Sacral Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards for a female resident with an unstageable sacral pressure ulcer and an indwelling Foley catheter. The resident, who had diagnoses including sepsis, CHF, and wasting syndrome, was moderately cognitively impaired and dependent for toileting hygiene. Her care plan identified an actual impairment to skin integrity with a sacral wound initially documented as stage 3 and later as unstageable, with specific orders to cleanse the coccyx pressure ulcer with wound cleanser, dry with gauze, apply Thera Honey and calcium alginate, and cover with bordered silicone gauze daily and as needed. An order was also in place for a urinary catheter for 30 days to aid wound healing. During an observed wound care procedure, the WCN removed an old sacral dressing that was saturated with urine and did not ensure the resident had a clean brief prior to performing wound care. The WCN failed to perform proper hand hygiene and glove changes when moving between dirty and clean tasks. She did not sanitize or wash her hands and change gloves before re-entering a package of clean wipes after handling contaminated areas, and she touched a urine- and feces-soaked brief during wound care without subsequently cleaning her hands or changing gloves. The WCN also applied an inadequate amount of hand sanitizer and did not allow it to dry before donning gloves. The WCN did not use proper wound cleansing technique, cleaning the sacral wound from the outside to the inside and wiping from top to bottom instead of from the inside to the outside (clean to dirty) in a circular motion as described by the DON. The WCN acknowledged that the Foley catheter, ordered to assist with wound healing, constantly leaked and that the resident’s brief stayed wet, but she did not address this issue during care. She stated she should have ensured a clean brief before wound care and recognized that her wound cleansing technique and handling of contaminated items could have caused cross-contamination. The NP reported she had not seen the wound and had not been notified of significant changes in the wound’s size or condition, other than the request for a Foley catheter order, despite the wound measurements fluctuating and the development of slough. The DON confirmed that re-entering clean supplies with contaminated gloves, improper wound cleansing technique, and failure to report the leaking Foley catheter were inconsistent with facility policies on wound care and hand hygiene.
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