THOMASTON, GA- PROVIDENCE HEALTHCARE

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35062

Based on observation, staff interview, record review, and review of facility policy titled Skin Management Standards, the facility failed to provide wound treatment per the physician’s order and failed to wash/sanitize hands and change gloves during wound treatment for one resident (R) (R67) of three residents reviewed for pressure ulcers. This deficient practice had the potential to place R67 at risk for medical complications and infection.

Findings include:
A review of the undated facility policy titled Skin Management Standards, revealed the procedure for dressing change:
1. Check the doctors’ orders for the type and frequency of dressing and any special instructions required for performing the procedure, including pre-medication for the resident’s comfort.
6. Wash/ Sanitize hands, put on clean gloves, remove soiled dressing, and discard immediately in a plastic bag.
7. Remove gloves, and place them in a plastic bag.
8. Wash/ sanitize hands.
9. Put on a pair of clean gloves.
10. Clean the wound from the center of the wound in a circular motion .
11. Discard gloves.
12. Wash/ sanitize hands.
13. Put on a pair of clean gloves.
14. If ordered, apply medication and topical treatment to the wound.

A review of the Minimum Data Set (MDS) Significant Change assessment dated [DATE] revealed R67 was not able to complete the Brief Interview for Mental Status (BIMS) score assessment, and had diagnoses including neurological condition, paraplegia, and malnutrition. The resident had one stage 4 pressure ulcer that was not present on admission.
A review of the current February 2024 Physician’s Orders revealed the following orders:
1. Sacrum: Clean sacrum with Dakin’s, apply crushed Flagyl 500 milligrams (mg) (a medication used to treat infections) to the wound bed, then apply Dakins 0.5% (a topical antiseptic used to clean infected wounds and ulcers) moistened gauze to wound bed/undermining, super absorbent, cover dry protective dressing such as superabsorbent adhesive – every day shift for Treatment Plan for Sacrum and as needed for misplaced or soiled dressing.
2. Clean Left Elbow, cleanse wound, pat dry, apply Flagyl directly to the wound bed then apply Dakin’s 0.5% moistened gauze to the wound bed, cover with dry protective dressing such as rolled gauze secured with tape or composite. Change Daily/PRN (as needed). Flagyl Oral Tablet 500 mg – Apply to Left Elbow topically every day shift for Treatment to Left Elbow.
3. Left Elbow Medial, cleanse the wound with NS (normal saline) or Dakin’s, pat dry, apply Santyl (an ointment used to remove damaged tissue from chronic skin ulcers) nickel thick to the wound bed, cover with calcium alginate for drainage management, then cover with dry protective dressing such as rolled gauze secured with tape or composite, every day shift for Treatment For medial Elbow and as needed for misplaced or soiled dressing. Physician Documentation dated 11/28/2023 revealed pressure ulcers to the sacrum, coccyx, heels, and hips- unavoidable.
During observation of wound care on 2/25/2024 at 6:25 am, Licensed Practical Nurse (LPN) BB started treatment to the sacrum. The dressing dated 2/24/2024 was removed. The sacrum wound was cleaned with Dakin’s, and crushed the Flagyl was placed on the Dakin’s soaked gauze which was then placed on the wound bed. LPN BB did not change gloves or sanitize hands after cleaning the wound and before applying the medication. The Dakin’s soaked gauze was not placed into the undermining of the wound. LPN BB completed the treatment, changed gloves, sanitized hands, and moved to the next wound. LPN BB cleaned the left elbow, applied Flagyl to the wound bed, and applied Dakins’ soaked gauze and a dry protective dressing. She then cleaned the medial left elbow with Dakin’s, applied Santyl to the wound bed, and covered it with calcium alginate and a dry protective dressing. The treatments to the left elbow and medial left elbow was performed according to the physician’s order. However, LPN BB failed to change gloves and sanitize hands after cleaning each wound and between each wound treatment.

An interview with the LPN BB on 2/25/2024 at 7:30 am revealed that she normally sanitizes hands and changes gloves after cleaning and before placing medication and also, she would normally place the Dakin’s soaked gauze into the undermining with a cotton swab. She stated she was nervous.