During a certification survey performed by the Department of Health in March of this year, Cobble Hill Health Center, a Brooklyn nursing home, received deficient ratings in several areas of care. Among these areas was a failure to properly establish an infection control program, in violation of federal regulation.
The violation documented by the DOH at Cobble Hill involves the treatment and cleansing of an elderly resident’s pressure ulcers. The resident was suffering from two pressure ulcers at the time of the incident: a Stage II wound of the right knee, and a Stage IV sore of the left ankle. The policy for cleaning pressure ulcers in place at Cobble Hill is very specific, as noted in the DOH report. It provides a step by step process, including when and how the staff member must wash his or her hands and change sterile gloves during treatment. During this particular wound cleansing, the nurse failed to follow this procedure. While treating the two wounds, the nurse failed to follow the procedures in place both for washing her hands and for changing her gloves. She also failed to provide a sterile area on which to rest the wounds while in the process of cleansing them.
As has been noted numerous times in the past here, the the development of pressure ulcers for an elderly nursing home resident is extremely painful and potentially deadly. Proper treatment of these wounds is essential to heal them as quickly as possible, and prevent possible infections from developing. In an interview with the Department of Health after this survey, the nurse acknowledged that she failed to follow protocol. She also relayed to the DOH that she would request further instruction regarding tending for these types of wounds. Fortunately her breach of protocol did not lead to any further harm for the resident. Perhaps this incident will lead to a more stringent application of the facility’s policies and procedures moving forward.
The full results of the Department of Health survey can be accessed here.