IDPH has cited and fined Bethany Rehab nursing home after a resident there died due to a bed sore that went largely untreated in the nursing home and became infected due to poor care.
“Bed sores” are the commonly used term for pressure ulcers, which are breakdowns in the skin which can lead to infections and other serious negative health consequences. There are specific federal regulations which address the development and care of bed sores, so they are a source of intense focus in the long-term care industry.
There are a number of factors which place a resident at risk for developing bed sores. The most common are immobility, incontinence, and poor nutritional status. There are other factors as well, and these are wrapped into an assessment tool known as the Braden Scale, which measures the resident’s risk of developing bed sores.
When the resident was admitted to the nursing home, she was coming directly from a local hospital. The discharge summary from the hospital included, amongst other ailments, a “sacral suspected deep tissue injury hospital acquired, (adhesive foam dressing) sacrum dressing changed every 3 days and as needed.”
Unfortunately for the resident, the admission assessment at the nursing home indicated that the new resident did not in fact have any impairment in skin integrity. This was in direct contrast to the discharge summary from the hospital.
Two weeks later, a nursing note continued to acknowledge the hospital acquired sacral deep tissue injury. The nursing note indicated that the resident had “no new issues” regarding her skin integrity.
It was only approximately 5 weeks after the date of admission that a nursing note indicated “wound care provided to sacral area.”
Every weekly skin assessment, from the date of admission, made no mention of the sacral deep tissue injury that was acquired in the hospital prior to admission.
A few days after the first mention of the wound in a nursing note, a new note indicated that “resident found with eye open nonverbal but will track you with eyes, wound on coccyx bleeding now, dressing applied, 911 ambulance took resident to (local emergency room) for eval.”
The report from the emergency room states that there was a “quarter sized circular opening mid lower sacrum/coccyx draining serosanguinous fluid. Skin over the lower back is warm, hot, erythematous, and tender. Able to express fluid with palpation. Foul smelling drainage.”
Unfortunately, the resident was operated upon, suffered cardiac arrest, and passed away several days later. The resident’s Death Certificate showed cause of death as sepsis, gluteal abscess necrotizing fasciitis and atrial fibrillation.
There are a couple of significant failures in the care of this resident which led to her death:
- There was an initial failure to document the bed sore that was clearly mentioned in the discharge summary from the local hospital. If the admission assessment had acknowledged the wound, steps could have been taken to address the bed sore at an early stage.
- Despite the existence of the hospital acquired bed sore, there was a delay in excess of five weeks before the nurses notes mention any treatment of the bed sore.
There are likely other failures. The sad fact about bed sores 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.
These systemic failures are often a sign of an understaffed nursing home. Sadly, that is a basic part of the nursing home business model. 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.
