IDPH has cited and fined Doctors Nursing & Rehab Center in Salem after a resident there was hospitalized due to a bed sore that became infected due to poor care.
“Bed sores” are the commonly used term for pressure ulcers, which are breakdowns in the skin which can lead to infections and other serious negative health consequences. There are specific federal regulations which address the development and care of bed sores, so they are a source of intense focus in the long-term care industry.
There are actually two separate federal regulations which address the topic of bed sores. The first relates to what is required when a resident is admitted to a nursing home without bed sores. This provides in essence that a resident should receive care necessary to prevent the development of pressure ulcers unless the clinical condition of the resident demonstrates that they were unavoidable – which is a very high standard to meet. The second addresses what happens after a resident has a bed sore. In essence it provides that a resident must be provided care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new bed sores.
When this resident was admitted to the nursing home, it was initially observed that there was a “wound to the Coccyx, two open areas, (area) measures 2 by 4 with a depth of 0.1, light clear serous drainage, well defined edges, with 100 percent of the wound covered by granulation tissue.” No stage of the wound was documented.
Over the next two months the nursing wound assessments indicate that the wound was stable for a period, then declined, then improved slightly, then declined again. Ultimately, after approximately 8 weeks in the facility, the resident was rushed to the hospital with a Stage 4 wound that developed an infection, requiring Intravenous (IV) antibiotic therapy, and surgical debridement. Worse, sepsis had set in.
While all wounds may fluctuate in their status, the failure of the nursing home in this case revolved around the lack of care provided by multiple staff members.
The first failure involved the wound care physician. The resident initially received adequate care (for about four weeks). At this four week mark however, the physician documented that “the patient’s visit has been rescheduled. No nurse available for rounds.”
One nurse noted in the citation that she was unsure as to why the wound doctor’s notes would read that a nurse was not available for a round, as any of the nurses could round with the wound care physician.
Unfortunately for the resident, there were no further evaluations of the wound by the wound care physician, as he was absent from the facility. Ultimately, it was explained that the wound care physician “was on an extended medical leave and was not (and would not) be available.”
The second failure involved the primary care physician. One nurse at the facility claims that she had reached out to the primary care physician once the wound care physician was no longer available.
The primary care physician, however, denies having been contacted by the facility regarding the deteriorating wound. In fact, she claims that she is always available directly by phone and was even in the facility making her rounds and could have easily examined the wound if she had been informed of the situation.
The last failure involves the medical director at the facility. While a nurse did contact the director, he did prescribe new treatment orders, but failed to stop by the resident’s room to examine the wound himself.
A full month after the last visit by the wound care doctor, the night nurse reported that the resident had a fever of 104 degrees fahrenheit, and that the “urine in (indwelling catheter) bag noted to be dark and cloudy with small clots observed.”
The resident was sent to the hospital and was diagnosed with “septic shock secondary to sacral wound.” Patients with advanced bed sores such as this resident are at high risk for going into septic shock due to open wounds created by the bedsores and the body’s inherently weakened condition as a result of the underlying wounds.
There are likely a long list of other failures. The sad fact about bed sores is that these are injuries which do not occur in a flash moment of time such as with a nursing home fall or a choking accident. Rather these were failures that spread across multiple days, multiple shifts, multiple staff members.
In this case these systemic failures are a sign of an understaffed nursing home, and border on neglect. Sadly, that is a basic part of the nursing home business model. 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. Order our FREE report, Built to Fail, to learn more about why. 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.
