Unsanitary Wound Care Performed Without Clean Barriers
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and treatment in a sanitary manner, contrary to its own wound management and treatment policies. The Menorah House Wound Management Program policy states that all caregivers are responsible for preventing, caring for, and treating wounds and skin alterations, with an organized approach that includes appropriate local wound care and prevention of skin breakdown. The Menorah House Treatment Procedure requires that a clean field be arranged per facility protocol when performing treatments inside a resident’s room. Despite these policies, surveyors observed wound care being performed without maintaining a clean barrier between open wounds and potentially contaminated surfaces. For one resident with a sacral pressure ulcer and multiple comorbidities including diffuse traumatic brain injury, diabetes mellitus type II, dementia, seizures, hypertension, and atherosclerotic heart disease, the physician’s order directed daily cleansing of the sacral wound with normal saline, patting dry, and applying collagen and calcium alginate with a dry dressing. The resident’s care plan focused on weekly skin checks, documenting wound status and healing, monitoring for signs and symptoms of infection, and encouraging participation in toileting and hygiene. During an observed sacral wound dressing change, an LPN, assisted by a CNA, prepared supplies and washed her hands, but did not place a clean barrier between the resident’s uncovered sacral wound and the diapered bottom. The LPN left the bedside to wash her hands, leaving the bare, exposed wound resting directly on a contaminated diaper and contaminated Hoyer lift net padding. Throughout the procedure, the resident’s uncovered sacral wound repeatedly came into contact with the contaminated diaper and Hoyer lift net padding, with no clean barrier used at any time. For another resident with a mid-upper back pressure ulcer and diagnoses including COPD, hypertension, GERD, and epilepsy, the physician’s order directed cleansing the mid-back wound with normal saline, patting dry, applying Medi-honey to the wound base, and covering with a dry dressing daily. The care plan for this resident also included weekly skin checks, documenting wound status and healing, monitoring for signs and symptoms of infection, and encouraging participation in toileting and hygiene. During an observed mid-upper back wound dressing change, the same LPN, assisted by the CNA, performed the dressing change without placing a clean barrier between the resident’s bare, uncovered back wound area and the contaminated bedding. Throughout the procedure, the resident’s uncovered back wound area was allowed to come into contact with the contaminated bedding while the wound was being cleaned and treated. In interviews, the LPN acknowledged not placing a clean barrier and could not explain why, and the unit manager and DON acknowledged that a clean barrier should have been used and that the dressing changes should have been performed in a safe and sanitary manner.
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