IDPH has cited and fined Crestwood Rehabilitation Center for negligence in identifying, assessing, and treating a change in the resident’s skin condition that led to the development of an unstageable, necrotic (meaning death of an area of living tissue) pressure ulcer, causing unnecessary pain, suffering, and hospitalization for the resident.
Despite the resident’s care plan that stated he had the potential for impairment to his skin integrity and should be monitored for any skin injury, the facility failed to take appropriate action to prevent and detect skin breakdown.
The facility’s lack of monitoring and assessment practices allowed the resident’s pressure injury to progress to an alarming state before being discovered.
In an initial assessment of the patient a wound care physician found an unstageable pressure injury on the resident’s sacrum, measuring 9 cm in length by 9.5 cm in width. This discovery highlights the facility’s failure to identify the wound at an earlier, more treatable stage. As the wound care nurse/coordinator stated “if everyone is doing everything they should be doing, a wound should be identified before it becomes necrotic.”
The facility’s continued neglect of the resident’s wound led to further deterioration, with the sacral pressure ulcer declining to 11 cm in length by 9 cm in width, with symptoms of infection, including odor. The Wound Physician commented that the resident “needs surgical debridement and recommends he be sent to the hospital for further evaluation and treatment,” underscoring the severity of the situation and the facility’s failure to provide timely and appropriate care.
The importance of prompt identification and treatment of skin changes was emphasized by both a registered nurse and a certified nursing assistant. The RN stated, “it is important to identify skin changes right away so it does not worsen and progress to a pressure ulcer.” The RN further said “it is important to catch skin changes early to start the healing.”
The facility’s systemic failure to adhere to proper wound prevention, assessment, and treatment protocols resulted in the development of an unstageable, necrotic pressure ulcer, which ultimately required hospitalization. This lack of care subjected the resident to unnecessary pain, suffering, and risk of further complications, highlighting the facility’s inability to provide the level of care and attention required to ensure the well-being of its residents.
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.
