IDPH has cited and fined Symphony Northwoods when a resident developed a severe pressure ulcer on his right heel that went unnoticed until it became necrotic and unstageable.
The resident in question was admitted to the facility with various diagnoses including Type 2 Diabetes, Atrial Fibrillation, Cellulitis of the Left Lower Limb, Lymphedema, Muscle Weakness, Acute Cystitis, and Morbid Obesity.
The pressure ulcer was first documented in the resident’s Progress Notes, which stated, “Necrotic tissue on bottom of Right heel surrounded by slough. Resident Unaware of wound. Wound care nurse notified. NP notified. POA updated. Foam boots applied.” The following day the wound was assessed as “unstageable to right heel, wound bed necrotic.”
An LPN and wound nurse provided insight into the resident’s care, stating, “He came from the hospital. He was resistive to all care, pericare, therapy.” The LPN also mentioned that the resident refused to wear boots or have his heels elevated on a pillow, claiming it was uncomfortable. The wound nurse performed dressing changes on the resident’s legs three times a week but noted that the resident would not allow more frequent care.
The resident himself expressed frustration with his care, stating, “The heel on my right foot got a terrible pressure sore on it that I am still working on healing today (at another facility). I looked at all my records from when I was in the hospital the first time and there was no mention of a pressure sore so I know I got it there.” He also mentioned that he had been begging for wound care for a week before the severe ulcer was discovered.
An RN recounted the discovery of the wound: “He had been complaining of right leg pain. He had had therapy earlier and a CNA was getting him ready for bed. He complained of right heel pain. She asked me to come look at it. It was black and full of necrotizing tissue.” This suggests that the wound had developed to a severe state before it was noticed by staff.
The Nurse Practitioner admitted to being unaware of the heel wound, stating, “I didn’t know anything about his heel. He never complained of pain to his heel, the pain was in his hip.” This indicates a potential breakdown in communication among the care team.
The facility’s Skin Management Program policy states, “It is the policy of the facility that a guest does not develop pressure injury unless clinically unavoidable.” The policy also requires that “A Braden Scale will be completed upon admission, weekly for 4 weeks, quarterly and with a significant change of status by a licensed nurse to determine the risk of pressure injury development.”
The resident’s Braden Scale score on admission was 15, indicating he was “At Risk” for pressure ulcers. Despite this, there were no orders for heel lift boots or off-loading of the resident’s heels in his Physician’s Order Sheet.
The severity of the neglect is evident in the Hospital Discharge Summary which lists one of the resident’s admitting and discharge diagnoses as “Decubitus Ulcer of right foot- s/p excisional debridement.”
This case highlights significant failures in wound prevention, early detection, and treatment protocols at the facility. Despite the resident being identified as at-risk for pressure ulcers upon admission, appropriate preventive measures were not implemented, and staff failed to detect the developing wound until it had reached a severe, necrotic state. This incident raises serious concerns about the quality of care and adherence to established policies at the facility.
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