Woods Edge Rehab And Nursing

Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 was cognitively impaired and dependent on staff for activities of daily living (ADL).

Was assessed to have a stage IV pressure ulcer (a severe, full-thickness wound with extensive tissue loss, exposing muscle, tendon, ligament, or bone) on his left heel. An observation of wound care and dressing change to the left heel of Resident #15 on 11/25/25 at 1:21 P.M. with Licensed Practical Nurse (LPN) #106, LPN#174, and Certified Nursing Assistant (CNA) #120. Resident #15 was noted to be in EBP.

Prior to putting on gowns and gloves, all staff washed and dried hands.

While LPN #106 was holding Resident #15's left leg up off the bed, LPN #174 used scissors to cut the old dressing, removed the soiled dressing and placed it in the trash with soiled gloves. LPN #174 washed hands and applied new gloves with no hand hygiene. LPN #106 asked where the wound cleanser was, then LPN #174 exited the resident's room with her isolation gown in place and returned with wound cleaner. LPN #174 applied gloves, cleansed the wound with gauze and cleaner, disposed of each gauze used to clean, removed soiled gloves and applied fresh gloves without any hand hygiene between. LPN #174 applied Santyl to gauze, applied gauze to left heel, wrapped the dressing in Kerlix, applied tape to dressing and exited room with her personal protective equipment (PPE) still in place. LPN #174 returned to room still in same gown and gloves, with a black marker, and initialed and dated the dressing.

Interview on 11/25/25 at 1:47 P.M., LPN #174 verified she should have removed the gown and gloves prior to exiting resident's room. LPN #174 verified she should have completed hand hygiene after removing the soiled gloves following the wound cleansing and prior to applying new gloves when she applied the wound treatment.

Interview on 11/25/25 at 9:21 A.M., DON stated the staff were expected to bring in all supplies prior to beginning any type of care the staff should be following the proper infection control techniques when doing wound care.

Subsequent interview on 12/01/25 at 9:47 A.M., the DON stated the facility policy on EBP included the proper use of gloves and gown and the facility policy on Aseptic Dressing Change included the proper hand hygiene.

The DON verified it was standard nursing practice to remove a gown prior to exiting a resident's room and applying a clean gown prior to re-entry, washing hands before you start wound care, anytime take your gloves off, touch anything soiled, going to clean dressing wash hands, and after you have completed the treatment.

The DON stated the staff were expected to follow policies and procedures for infection control.

Review of facility policy for Aseptic Dressing Change dated January 2024, revealed steps that include placing soiled dressing in trash, washing hands, applying clean gloves to cleanse wound, discarding cleansing supplies to trash, wash hands and apply gloves, apply medication and clean dressing, remove gloves and place in trash, tape dressing ion place, date and initial according to facility policy.

Review of facility policy on EBP dated March 22, 2024, revealed EBP for residents with wounds regardless of MDRO colonization status should be ordered and followed by staff during high-contact resident care activities including wound care.

These precautions include the proper application and removal of gloves and gown.

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