IDPH has cited and fined Aperion Care Westchester when the facility failed to perform pressure ulcer dressing changes as ordered by the physician. This failure resulted in the resident developing an infected right heel pressure wound.
The resident in question was admitted to the facility with an unstageable pressure ulcer on her right heel, measuring 5.5 cm x 6.8 cm x 0.1 cm, with light serosanguineous drainage. This initial condition, while serious, was manageable with proper care.
Approximately one month later, recognizing the need for intensive treatment, the resident’s physician ordered twice-daily dressing changes. The order specified cleansing the area with normal saline, packing with Dakins solution-soaked gauze, and covering with appropriate dressings. This rigorous care plan was designed to promote healing and prevent infection.
However, from the very beginning, there were signs of inconsistent care. The Treatment Administration Record (TAR) shows that dressing changes were missed on several occasions. This pattern of missed treatments continued over a two month period, with numerous days showing no documentation of the prescribed wound care.
In the midst of this two month period, the physician adjusted the order, likely in response to the wound’s condition, specifying that the dressing changes should occur during day and night shifts. Despite this emphasized instruction, the lapses in care persisted.
The consequences of this inconsistent treatment became alarmingly clear. A Wound Physician’s note revealed that the once unstageable pressure ulcer had progressed to a stage 4 pressure ulcer, now measuring 8.5 cm x 5 cm x 1.9 cm. The wound showed heavy purulent drainage, a clear sign of infection, and the physician noted that the wound’s progress was not meeting its healing goals.
In response to these concerning developments a wound culture was taken. The results confirmed the fears of infection, showing moderate growth of escherichia coli, proteus mirabilis, and enterococcus faecalis. This infection necessitated additional treatment, with antibiotics being prescribed to combat the bacterial growth.
Throughout this period the pattern of missed dressing changes continued, with gaps in care documented on multiple days. Each missed treatment represented a missed opportunity to combat the infection and promote healing.
When questioned about these lapses, the Director of Nursing emphasized the gravity of the situation, stating, “If it was not documented, it was not done.” This statement underscored the facility’s failure to adhere to its own Pressure Injury and Skin Condition Assessment Policy, which required staff to initial the electronic Treatment Administration Record after each treatment.
The resident’s Wound Physician further highlighted the critical nature of consistent wound care. The Wound Physician explained that if dressing changes are not performed as ordered, wounds can become infected, and existing infections can worsen, impeding the healing process.
This chronological account reveals a distressing pattern of neglect in the resident’s wound care. What began as a manageable, albeit serious, pressure ulcer deteriorated into a severe, infected wound due to inconsistent treatment.
There are likely a long list of other failures. The sad fact about pressure ulcers is that these are injuries which do not occur in a flash moment of time such as with a nursing home fall or a choking accident. Rather these were failures that spread across multiple days, multiple shifts, multiple staff members.
The story of this resident serves as a stark reminder of the crucial importance of adhering to prescribed care plans and the potentially severe consequences when such care is neglected.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
