IDPH has cited and fined Paris Health & Rehab Center when a resident developed complications from a pressure ulcer on their right heel, ultimately leading to hospitalization for osteomyelitis and the discovery of maggots in the wound.
The resident in question was admitted with multiple medical conditions including type 2 diabetes, pressure ulcer on the right heel, and hemiplegia following a cerebral infarction. The resident’s care plan included interventions for daily skin checks, floating heels, and monitoring for signs of infection.
The Wound Nurse Practitioner documented the resident’s right heel wound measuring 4.1 cm x 2.5 cm x 0.1 cm and applied a skin graft with specific dressing instructions. However, subsequent notes indicate issues with dressing adherence and odor.
Approximately two weeks later the situation drastically deteriorated. The Director of Nursing documented a change in the resident’s condition, noting “increased drainage and odor” from the wound. When the Wound Nurse Practitioner examined the resident, she found the wound had “foul smell and had deteriorated.” The Nurse’s assessment revealed “Strong odor and new wound beneath dressing when removed. Increased measurements. Wound declined with unstable eschar noted within wound bed.”
Most alarmingly, when the resident was admitted to the hospital shortly thereafter, the records state that “reportedly maggots were expressed from the wound along with malodorous material.” The following day an MRI confirmed “soft tissue ulcer in the plantar subcutaneous tissues inferior to the posterior calcaneal bone associated with both cellulitis and Osteomyelitis.”
Interviews with staff members revealed a concerning lack of proper wound care and communication. Multiple staff members noticed a strong odor in the days leading up to the admission to hospital, but failed to take appropriate action.
A Licensed Practical Nurse (LPN) stated, “the shower aide told the LPN that the resident’s odor was really bad and thought she was going to throw up from the smell. The LPN stated she informed the Business Office Manager regarding the strong odor but did not document anything about it or notify the Wound Nurse Practitioner.”
The Wound Nurse Practitioner expressed concern about the lack of communication, stating, “that she was not made aware of the strong pungent smell coming from the resident’s wound and should have been made aware.”
The resident himself reported, “the wound was smelling but staff didn’t do anything except agree that it smelled.”
This incident highlights significant failures in wound care management, staff communication, and adherence to care plans. Despite the resident being identified as high-risk for pressure ulcers with specific care instructions, staff members failed to properly monitor the wound, report concerning symptoms, or take timely action when issues were noticed. These lapses in care resulted in a severe decline in the resident’s condition, necessitating hospitalization and long-term antibiotic treatment for osteomyelitis.
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