Failure to Prevent Cross Contamination and Provide Timely Incontinence Care During Wound Management
Penalty
Summary
Surveyors identified a deficiency in providing appropriate treatment and care according to orders and in preventing cross contamination during wound care for one resident with coccyx wounds. The resident’s MDS documented moderate cognitive intactness and a need for assistance with toileting and personal hygiene, and the POS included an order to apply a hydrocolloid dressing to the coccyx every other day starting 2/23/26. On 2/25/26, the resident remained seated in a wheelchair from 9:00 AM to 1:00 PM without being provided incontinence care, despite being incontinent and requiring assistance. During wound care at 2:35 PM, an LPN gathered wound care supplies (gauze, dressing, scissors, wound cleanser) by holding them against her zip-up hoodie jacket and then placed the supplies on the resident’s bedside table before ensuring the table was disinfected. The previous dressing on the coccyx was a simple foam dated 2/23/26. At the time of the observation, the resident’s coccyx had an open, red wound approximately the size of a quarter with a non-blanchable peri-wound area, and a separate open, red, line-shaped wound approximately an inch long. The LPN acknowledged that she contaminated the resident’s wound care supplies by holding them against her contaminated jacket and stated that the coccyx wound had been the size of a pencil eraser a few days earlier and that the resident previously had no open areas on the right buttock. The wound nurse later stated that staff do not lay the resident down after breakfast as they should and attributed the open areas on the resident’s bottom to this, and also stated she was not aware that the coccyx wound had worsened or that there was a new area on the right buttock. The DON stated that staff are expected to provide incontinence care every two hours and as needed, and to provide preventative care such as repositioning and toileting to prevent wounds, and confirmed that the resident is incontinent and requires assistance with incontinence care.
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