IDPH has cited and fined Accolade Healthcare Danville when the facility failed to properly assess, monitor, and report a bruise/hematoma on a resident’s left foot, which ultimately led to a serious infection requiring hospitalization and surgical intervention.
The incident in question began when a “fresh, purple bruise” measuring 3 cm by 1 cm was discovered on the resident’s left foot. The resident reported that it likely occurred during a mechanical lift transfer the previous day.
Initial documentation and monitoring of the bruise were inconsistent and inadequate. While a Weekly Skin Assessment noted the bruise had grown to 5 cm by 2.5 cm, subsequent assessments on the following two consecutive weeks failed to mention the bruise at all, stating only that there were “no new or worsening skin conditions.”
The facility’s failure to properly monitor and report the worsening condition led to severe consequences. Approximately two and a half weeks after the initial reporting of the wound, the resident was hospitalized with “left foot swelling, fluctuance (boggy feeling due to buildup of fluid), redness and warmth.” The hospital diagnosed the resident with septic shock and a left foot abscess. The situation was so severe that a few days later, “purulence was expressed from the resident’s abscessed hematoma and a large hematoma was operatively removed.”
Upon the resident’s readmission to the facility, further lapses in care were evident. The readmission assessment noted “multiple stage one pressure ulcers on the right outer foot” without providing crucial details such as the number of wounds, their characteristics, or measurements. Subsequent assessments continued to lack necessary detail and consistency.
The facility’s staff, including nurses and wound care specialists, acknowledged these failures in care. A RN stated that “the area stayed the same from when it was first identified until the resident was hospitalized, and the area had not shown any signs of improvement.” The same RN also noted that “there should be documented monitoring and assessments for this area recorded on the Treatment Administration Record or progress notes,” which were clearly lacking.
A Nurse Practitioner emphasized the severity of the oversight, stating that “the facility staff should have been monitoring and assessing the resident’s hematoma, including characteristics, measurements/assessments, and monitoring for fever.” The Nurse Practitioner added that “it is a ‘strong possibility’ that the resident’s hospital incision and drainage may have been prevented if the resident was evaluated by the Wound Physician and antibiotics were ordered.”
The Wound Physician corroborated this assessment, stating that had the facility properly monitored and reported the hematoma, he “would have lanced and drained the hematoma at the facility, which could have prevented the resident’s hospital incision and drainage.”
This case highlights a systemic failure in wound care protocols, communication, and adherence to established policies, resulting in unnecessary suffering and complications for the resident.
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