Failure to Follow Wound Care Orders and Isolation Protocols for Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and adhere to infection control protocols for a resident with multiple complex medical conditions and stage 4 pressure ulcers. The resident was admitted with diagnoses including muscular dystrophy, muscle wasting and atrophy, muscle weakness, osteomyelitis of the sacral and sacrococcygeal vertebrae, paresthesia of the skin, underweight status, and multiple sclerosis. The MDS documented intact cognition and the presence of two stage 4 pressure ulcers. The care plan identified the resident as requiring contact isolation for MRSA, ESBL, and CRE involving the nares, sacrum, and vagina, and also documented risk factors for skin breakdown, including decreased mobility, contractures, history of ulcers, chronic osteomyelitis, and underweight status. Surveyors observed a wound dressing change during which staff did not follow the facility’s enhanced barrier precautions policy. An enhanced barrier precaution sign was posted on the resident’s door, but the RN performing the dressing change and assisting staff only wore gloves and did not don gowns. The RN removed a sacral dressing that was dated two days earlier and appeared dirty and soiled through with blood and green drainage, and a right buttock dressing that was also soiled with blood and green drainage and lacked a date. There was no dressing present on the vulvar wound at the time of observation. The RN then cleansed each wound with normal saline and applied calcium alginate and Silvadene cream mixed with collagen powder. Interviews and record review showed that physician orders required daily and as-needed dressing changes to the sacrum, vulva, and right buttock, and that the resident was on contact isolation for infected wounds. The RN acknowledged that the wound dressings had not been changed the previous day, not due to resident refusal but because she did not have time, despite the daily order. The RN also stated she could not locate the resident’s Silvadene cream and instead used another resident’s prescribed wound medication, contrary to facility policy that medications supplied for one resident are never administered to another. Additional staff confirmed they forgot to wear gowns during the wound care, despite the isolation signage and policies requiring gown and glove use for high-contact care under enhanced barrier or contact isolation precautions. The administrator confirmed expectations that staff follow physician orders, use resident-specific prescription creams, and wear required PPE for residents on isolation or enhanced barrier precautions.
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