Failure to Maintain Cleanliness During Stage 4 Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves a failure to follow proper infection control practices during pressure injury wound care for Resident 2, who was admitted with a stage 4 pressure injury to the sacrococcygeal area and osteomyelitis of the vertebra, sacral, and sacrococcygeal region. During an observed wound care procedure, the LVN performed a dressing change while the resident was wearing a soiled incontinence brief containing a small amount of brown feces. The LVN removed the old dressing, cleansed the wound with normal saline, completed the wound care, and then replaced the same soiled brief on the resident, stating that the brief was dirty with stool but that she would wait for a CNA to change it later. Resident 2’s records showed that the resident had decision-making capacity, no cognitive impairment, and was dependent on staff for ADLs including toileting and personal hygiene. The care plan directed staff to keep the resident’s skin clean and provide skin care per facility guidelines, and the physician’s order specified daily cleansing and dressing of the stage 4 pressure injury. Facility staff, including the LVN, RN, and DON, acknowledged that residents should be cleaned of stool and urine and provided with a clean brief before wound care to prevent contamination of the pressure injury. The facility’s pressure injury prevention and management policy stated that treatment and services are to be provided to heal pressure injuries and prevent infection, including minimizing exposure to moisture and keeping skin clean, especially from fecal contamination.
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