The Illinois Department Of Health has cited and fined Elevate Care South Holland when they failed to administer antibiotics to a resident when lab results indicated a bedsore infection. As a result of the failure to communicate the results to the resident’s doctor and nurses, the wound was left untreated for two weeks and progressed to a stage 4 bedsore and bone infection requiring hospitalization.
The resident in question was admitted to the facility with multiple conditions including a stage three pressure ulcer, quadriplegia (paralysis of all four limbs), and other health issues.
The incident began when a wound care specialist noted concerning changes in the resident’s pressure ulcer, including an unpleasant odor and greenish drainage. They ordered a wound culture (a test to check for bacteria) and requested an infectious disease consultation. The wound at this time measured 5 centimeters by 4 centimeters with a depth of 0.1 centimeters.
The lab results, which came back four days later, showed a serious infection: “high amount of bacteria greater than 100,000 of pseudomonas aeruginosa.”
Unfortunately, these results weren’t properly communicated to the necessary medical staff. As noted in the report: “the facility failed to follow their physician notification of laboratory/radiology/diagnostic results policy by not notifying the physician/nurse practitioner of a sacral wound culture results.”
The wound continued to worsen. An additional four days after the lab results were received it had significantly deteriorated, with the documentation showing it had grown to “8 centimeters length x 8.5 cm width x 2 cm depth” – a substantial increase in size and depth. The wound was now classified as stage 4, which is more severe than its previous stage 3 classification.
Due to the lack of communication about the lab results, the resident did not receive any antibiotic treatment. The report notes that “the resident’s medication administration record and physician orders did not document any new antibiotic treatment after the lab results were received.”
Two weeks after the culture results came back, the wound remained untreated and the resident had to be hospitalized with a diagnosis of sacral osteomyelitis (an infection in the bone).
Multiple healthcare providers interviewed stated they were unaware of the culture results. The Infectious Disease Nurse Practitioner stated “he was not aware of the resident’s wound culture results and would have ordered antibiotics for the resident.”
Another physician noted that “there should have been intervention sooner in relation to the wound culture results.” The facility’s own care plan had specifically called for staff to “monitor for signs and symptoms of infection (redness, warmth, swelling, pain, excessive drainage, odor) and notify provider.”
Unfortunately for this resident the wound monitoring and notification process at Elevate Care South Holland appears to have broken down.
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.
