Failure to Perform Skin Checks Leads to Severe Infected Pressure Ulcers At Generations At Applewood

The Illinois Department of Health has cited and fined Generations At Applewood when staff failed to perform required weekly skin assessments on a dependent resident who developed multiple severe pressure ulcers while in their care, ultimately resulting in a stage 4 sacral wound with necrotic tissue that became infected and required hospitalization and six weeks of intravenous antibiotics.

The resident in question was admitted with multiple medical conditions, including local skin infection, difficulty swallowing, peripheral vascular disease, hypothyroidism, gastroesophageal reflux disease, and chronic kidney disease. According to facility records, the resident developed three pressure ulcers (also known as bedsores) after her admission – a stage 3 ulcer on her right elbow, a stage 4 ulcer on her left leg, and a stage 4 ulcer on her sacrum (lower back).

The sacral wound was particularly severe. A wound assessment note described it as a “stage 4 pressure wound” that was “full thickness” with a size of “8.0 x 15.5” centimeters. The depth was noted as “unmeasurable due to presence of nonviable tissue and necrosis.” In other words, the wound was so deep and filled with dead tissue that its true depth couldn’t be determined.

The resident’s condition deteriorated to the point where she needed hospitalization. Hospital records indicated she was admitted from the nursing home with “pressure ulcer on the right elbow and worsening of sacral decubitus ulcer with foul smell draining pus.” The infection was serious enough that she required intravenous antibiotics (Vancomycin and Zosyn), a surgical consultation, and planning for surgical debridement (removal of dead tissue). The hospital determined she would need “more than 2 medically necessary midnights of in-hospital care because of sacral decubitus ulcer infection” and planned for her to continue antibiotics for a total of six weeks after returning to the nursing home.

Assessment records showed that the resident had mild cognitive impairment and was completely dependent on staff for all activities of daily living. She was also always incontinent of both bowel and bladder, putting her at high risk for skin breakdown if not kept clean and dry.

Despite having an order for weekly skin checks since her admission, there was no documentation of any skin checks in her medical record. The wound care nurse later admitted that “the wound team was just treating resident’s leg wound that was present on admission and were not aware of anything going on in resident’s sacrum” until several months after admission. She acknowledged that “the wound care team did not do another skin assessment apart from the one done upon admission” and that “the facility dropped the ball this time, there was a gap in communication, resident’s wound could have been identified earlier.”

During an inspection visit, the resident was observed lying in bed and stated that she had not been changed yet that day, having been last changed the previous day, and felt that she was wet. She also mentioned that no one had changed her wound dressing yet, and she didn’t know who her assigned nursing assistant was for the day.

Later that morning, a nursing assistant and restorative aide were observed leaving the resident’s room with dirty linens. When asked to show the resident’s soiled incontinence brief, inspectors noted “a large area of reddish stain that saturated the brief.” The nursing assistant claimed the resident “was not wet, the stain is from her wounds.” When the resident’s wounds were examined, inspectors saw “a large area of deep wound on resident’s sacrum that looks red, with lots of drainage.”

Disturbingly, staff applied a clean incontinence brief on the resident with no dressing covering the wound, promising to inform the wound care nurse that the resident’s wound didn’t have any cover. Several hours later, the resident was observed still lying on her back and stated that no one had come to turn her or put a dressing on her wound.

When wound care was finally observed by inspectors, the Director of Nursing and a Wound Technician removed the resident’s incontinence brief and found it “soaked with wound drainage and there was no dressing covering resident’s wounds.” The Director of Nursing admitted “she was not aware that the resident did not have any dressing to her wounds, no one informed her.” She acknowledged that “the wound should not be left without dressing because it will be losing hemostasis” – meaning the wound would continue to drain and potentially bleed without a proper dressing.

The facility’s own policies required that residents “will be assessed to determine their risk factor(s) for pressure injury development, upon admission; weekly x 4 weeks following admission/readmission and at least quarterly thereafter” and that residents would “have their skin checked and documented utilizing the Treatment Administration Record… at a minimum of weekly.” These policies were clearly not followed in this case, leading to the development and worsening of severe pressure ulcers that ultimately required hospitalization.

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.