IDPH has cited and fined Alden Debes Rehab & HCC when the facility failed to identify, reassess, document changes, and notify a care provider about a declining pressure wound. These failures led to an unstaged coccyx pressure injury worsening into a larger unstageable pressure injury, requiring hospitalization and extensive surgical debridement.
The resident in question was a cognitively impaired female at risk for developing pressure injuries, needing maximal assistance and/or dependence on staff for bed turning, transfers, bathing, and personal hygiene.
The Wound Care Nurse documented the resident’s new onset coccyx pressure injury, measuring 3 cm by 2.5 cm by 0.5 cm, with drainage and a brown/yellow wound bed. However, the progress note lacked staging classification and information about signs of infection.
Two separate CNAs observed changes in the resident’s wound, with one noting the dressing was wet and fallen off, and the wound was white with a little blood. The other CNA stated the wound was initially about the size of a quarter but later became bigger with a dark ring around it, resembling a bruise. An additional CNA noticed a foul odor coming from the resident’s room, describing it as “one of those fleshy infected smells.”
Despite dressing changes documented by an agency nurse two days and six days after the initial discovery of the wound, and by an LPN four days and five days later, no progress notes, wound notes, or documentation were found in the resident’s medical record regarding the wound’s condition during these dressing changes.
Five days after the discovery, a CNA observed the resident’s dressing had come off, revealing a wound about 2 inches across with a black center. The CNA informed the LPN, who replaced the dressing. However, the resident’s medical record lacked documentation by the LPN about the wound’s condition or the dressing reapplication.
The Wound Care Nurse Practitioner stated she was not notified about the resident’s wound changes and was not contacted for wound care orders. The resident’s NP was notified of a new leg wound three days later but not the new coccyx wound.
Approximately a week after the initial discovery the resident was sent to the hospital, where a Nurse discovered a 2-3-inch round coccyx pressure wound with purulent dark drainage, a black bottom, and bone exposure. The resident was admitted to the ICU with sepsis and underwent surgical debridement, revealing dead tissue down to the bone in a wound measuring 30 cm x 10 cm x 4 cm deep.
The resident expired 10 days after being admitted to the hospital, with causes of death listed as multiple organ failure, sepsis, and coccyx decubitus pressure ulcer.
The facility’s Pressure Injury Policy required weekly assessments and comprehensive evaluations for identified pressure injuries, but the resident’s medical record lacked entries of such assessments or care plan updates after the coccyx wound was found.
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.
