F0686

D

Improper Wound Care and Infection Control During Pressure Ulcer Treatment

El Paso, Texas Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide wound care and maintain infection prevention and control practices for a resident on transmission-based precautions with multiple Stage 4 pressure ulcers. The resident was an elderly female with a history of Type 2 diabetes mellitus, cerebrovascular disease, anoxic brain damage, and sarcopenia, who was unable to participate in the BIMS and unable to answer questions due to her medical condition. Her physician orders required daily and PRN wound care for Stage 4 pressure wounds on the left buttock, right buttock, and sacrum, and her care plan included wound care and administration of Arginaid as ordered. A wound care progress note documented that all wound sites were healing with no signs of infection.

During an observation of wound care, the Wound Care RN applied Arginaid, a powder-form nutritional supplement, directly onto the resident’s right and left buttock wounds. The powder was observed spilling from the wounds onto the resident’s brief. The Wound Care RN then secured the brief on the resident without changing it, leaving the spilled medication on the brief. In a subsequent interview, the DON stated that wound care nurses were responsible for providing wound care per facility policy and that it was not acceptable for the Wound Care RN to leave a brief on the resident with contaminated spilled medication, acknowledging that this could lead to possible infection or illness and could infect the resident’s other wounds. The facility’s wound treatment management policy stated that wound treatments would be provided in accordance with physician orders and that dressing changes may be provided outside the usual frequency when the dressing is soiled or otherwise wet.