Elevate Care South Holland Resident Develops Infection In Bone From Bedsore

IDPH has cited and fined Elevate Care South Holland nursing home after a resident there developed sacral osteomyelitis from a bed sore which was not properly treated.

The resident suffered from a Stage 3 bedsore. Bed sores are rated or “staged” on a 1-4 scale, with a Stage 4 being the worst. A Stage 3 bedsore is one where the deeper tissues beneath the skin are exposed, but there is no exposure of muscle, tendon, or bone. One of the functions of intact skin is that it serves as a barrier to infectious bacteria, and a Stage 3 bedsore is an interruption in the integrity of the skin.

Federal regulations require that nursing home residents who have a bed sore receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new bedsores.

When a resident develops a bedsore, management of care of the bedsore is often assigned to a wound care doctor or wound care nurse who oversees the care of the bedsore. However, nurses on the floor are still required to provide day-to-day care and to monitor the condition of the bedsore, including monitoring for signs of infection.

When the wound care doctor was providing care, he saw signs of infection, including malodor and greenish drainage. The wound care doctor ordered a culture of the wound. The wound culture was obtained and sent to the lab.

One of the ways in which care provided in a nursing home is different from care provided in a hospital setting is that doctors are not on site 24/7. Therefore, when doctors are not present in the facility, it is up to the nursing staff to act as the “eyes and ears” of the doctor, including notifying the doctor of any changes in condition or any abnormal lab results. This allows the doctors to make decisions regarding the treatment of residents under their care.

Four days after the culture was obtained, the lab faxed the results of the culture back to the nursing home. It showed that the wound was indeed infected with multiple strains of bacteria. Despite the abnormal lab results, none of the responsible health care providers – the wound care doctor, the attending physician, or the infectious disease nurse practitioner – were notified of the abnormal lab results. Each told the IDPH surveyor that had they been advised of the culture results, antibiotics would have been ordered for this resident.

Because the antibiotics were not ordered, the infection was allowed to progress, and a little over three weeks later, the resident was sent to the hospital where the diagnosis was sacral osteomyelitis. Osteomyelitis is an infection of the bone which can be intensely painful.

Nursing homes are businesses, and well-run businesses have systems in place which ensure that the regular functions of the business (and notifying doctors of abnormal lab results is one) are carried out on a day-to-day basis. There was clearly a breakdown of that system here, and led to a serious infection for this resident. One of our core beliefs is that the nursing home business model too often results in unnecessary injuries, illnesses, and deaths for nursing home residents, and the failure to invest in the training necessary to ensure that systems are implemented is a part of the nursing home business model.