IDPH has cited and fined Generations Oakton Pavillion nursing home in Des Plaines after a resident there developed an infection of a bed sore after the staff failed to use a wound vac on a bed sore as ordered.
There are two federal regulations which address the topic of bed sores. In essence, these provide (1) that a resident who enters a nursing home without bed sores should not develop them unless they are clinically unavoidable and (2) once a resident does have a bed sore, residents must receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new bed sores. Once a resident develops a bed sore, this requires the nursing staff to notify the physician to get treatment orders and revision of the resident care plan.
Bed stores are staged or rated as Stage 1 through 4, with Stage 4 being the worst. Stage 4 bed sores involve exposed muscle or bone. Because these are so deep and involve major breaches of the integrity of the skin, these place the resident at risk for suffering infections such as cellulitis or osteomyelitis.
One of the tools that is available to treat Stage 4 bed sores is a device known as a wound vac. The wound vac is a device in which a dressing (usually impregnated with substances to help promote healing) is placed in the wound bed and a seal is applied over the borders of the wound. When the seal is not good, the wound vac will make a beeping noise which alerts the nursing staff of that. The wound vac is then applied to the dressing and it removes drainage from the wound bed. This helps promote healing and prevent infection.
The resident as issue was admitted to the nursing home with a Stage 4 bed sore to his sacrum measuring 11 cm x 8 cm x 2 cm. There was no odor to the wound and it had heavy serosanguinous drainage (a clear or bloody drainage that is present in a healthy, healing wound). There were orders in places for use of a wound vac or alternatively for use of an antiseptic soaked gauze if the seal on the wound vac would not be achieved. Wound vacs should be run continuously unless there is a dressing change being done, and in this nursing home, all wound vacs have signs on them saying to not shut it off.
On the fourth day after the resident was admitted to the nursing home, when the day shift nurse arrived on Monday morning, she went into the resident’s room and noticed a foul odor in the room. She went to check the resident’s dressing and found that the wound vac had been shut off. She then notified the wound care nurse who then assessed the resident and found that there was no seal, that the dressing was soaked, that the wound bed had a foul odor with maceration and erythema of the wound edges – all potential signs of infection. There was no documentation as to how long the wound vac was off, but the day shift nurse told the wound care nurse that there had been problems with the machine beeping, so they shut the machine off.
A wound culture was done which showed that the wound was in fact infected. The resident was then sent to the hospital for further treatment which would have likely included the use of IV antibiotics and/or surgical debridement of the wound.
The key issue here is the failure to know what to do when there is not a good seal on a wound vac. There are a few options: (1) attempt to place a new dressing in the wound bed and put a new seal over the wound, (2) follow facility protocols and notify the wound care nurse that the machine is beeping and allow to try to resolve the issue, or (3) follow the orders that were in place an apply the antiseptic dressing to the wound. Instead of pursuing any of those options, the staff on duty simply shut the machine off despite a sign on the machine saying not to do so. That resolved the problem with the beeping noise but denied the resident the care that he needed with infection of the wound being the net result.
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Other blog posts of interest:
Infection results from failure to care for surgical wound at Arcadia Care of Morris
Victorian Village resident develops pressure ulcer from orthotic boot
Failure to treat pressure ulcer at Franciscan Village in Lemont
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