Failure to Accurately Document Skin Assessments and Perform Hand Hygiene During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess and document a resident’s skin condition and to perform proper hand hygiene during pressure ulcer care. A cognitively intact resident with paraplegia, neurogenic bowel and bladder, renal failure, chronic pain, and a history of a recurrent stage 4 pressure wound to the left gluteal crease was care planned as being at risk for pressure ulcers and requiring regular skin monitoring and treatments. The quarterly MDS documented that the resident did not have a pressure ulcer, and a weekly nursing skin assessment recorded no alterations in skin integrity, despite a note that a small blister had been charted the previous day. A weekly non‑pressure wound assessment completed by the former ADON/wound nurse documented only a ruptured blister on the inner upper right hip and did not list any additional wounds. Progress notes later documented that, during a neurogenic bowel treatment, nursing staff observed an open skin impairment to the right gluteal fold with granulation tissue, defined borders, peeling/excoriated periwound skin, and serosanguineous drainage with purulent drainage, measuring 4.5 cm x 5.0 cm x 0.2 cm. The nurse cleansed and dressed this wound, indicating that a significant wound was present but had not been captured on the weekly skin or wound assessments. Staff interviews revealed that the nurse who completed the weekly non‑pressure wound assessment had actually performed the assessment on a different day than documented, focused only on known areas of concern, and did not perform a full head‑to‑toe assessment, contrary to facility policy requiring a full body skin assessment and documentation of all wounds and their characteristics. The facility also failed to ensure proper hand hygiene during a pressure ulcer treatment to the resident’s left gluteal fold. During observation of a neurogenic bowel treatment and dressing change, two RNs initially washed their hands, but one RN then touched her hair, picked up wipes from the floor, and moved a trash can before proceeding with care. Throughout the procedure, both RNs repeatedly doffed and donned gloves between steps such as removing the old dressing, cleansing the wound, and applying the new dressing, without performing hand hygiene between glove changes, despite handling stool and the wound area. The facility’s hand hygiene policy required staff to perform hand hygiene using proper technique consistent with accepted standards of practice, and the DON stated that hand hygiene should be performed between glove changes during wound treatments, but this was not followed during the observed care.
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