IDPH has cited and fined Aperion Care Westchester when the facility failed to perform pressure ulcer dressing changes as ordered by the physician. This failure resulted in the resident developing an infected right heel pressure wound.

The resident in question was admitted to the facility with an unstageable pressure ulcer on her right heel, measuring 5.5 cm x 6.8 cm x 0.1 cm, with light serosanguineous drainage. This initial condition, while serious, was manageable with proper care.

Approximately one month later, recognizing the need for intensive treatment, the resident’s physician ordered twice-daily dressing changes. The order specified cleansing the area with normal saline, packing with Dakins solution-soaked gauze, and covering with appropriate dressings. This rigorous care plan was designed to promote healing and prevent infection.

However, from the very beginning, there were signs of inconsistent care. The Treatment Administration Record (TAR) shows that dressing changes were missed on several occasions. This pattern of missed treatments continued over a two month period, with numerous days showing no documentation of the prescribed wound care.

In the midst of this two month period, the physician adjusted the order, likely in response to the wound’s condition, specifying that the dressing changes should occur during day and night shifts. Despite this emphasized instruction, the lapses in care persisted.

The consequences of this inconsistent treatment became alarmingly clear. A Wound Physician’s note revealed that the once unstageable pressure ulcer had progressed to a stage 4 pressure ulcer, now measuring 8.5 cm x 5 cm x 1.9 cm. The wound showed heavy purulent drainage, a clear sign of infection, and the physician noted that the wound’s progress was not meeting its healing goals.

In response to these concerning developments a wound culture was taken. The results confirmed the fears of infection, showing moderate growth of escherichia coli, proteus mirabilis, and enterococcus faecalis. This infection necessitated additional treatment, with antibiotics being prescribed to combat the bacterial growth.

Throughout this period the pattern of missed dressing changes continued, with gaps in care documented on multiple days. Each missed treatment represented a missed opportunity to combat the infection and promote healing.

When questioned about these lapses, the Director of Nursing emphasized the gravity of the situation, stating, “If it was not documented, it was not done.” This statement underscored the facility’s failure to adhere to its own Pressure Injury and Skin Condition Assessment Policy, which required staff to initial the electronic Treatment Administration Record after each treatment.

The resident’s Wound Physician further highlighted the critical nature of consistent wound care. The Wound Physician explained that if dressing changes are not performed as ordered, wounds can become infected, and existing infections can worsen, impeding the healing process.

This chronological account reveals a distressing pattern of neglect in the resident’s wound care. What began as a manageable, albeit serious, pressure ulcer deteriorated into a severe, infected wound due to inconsistent treatment.

There are likely a long list of other failures. The sad fact about pressure ulcers 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.

The story of this resident serves as a stark reminder of the crucial importance of adhering to prescribed care plans and the potentially severe consequences when such care is neglected.

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.

IDPH has cited and fined Allure of Zion for neglecting to conduct regular skin assessments of its residents for a period of 4 weeks. This lapse in care allowed a resident’s bed sore to get worse and worse, progressing from to Stage 3 in just 5 days, and ultimately deteriorating to Stage 4, exposing the bone and requiring surgical debridement due to dead (necrotic) tissues.

The facility’s disregard for the resident’s well-being was further highlighted by the resident’s granddaughter, who noted that during her visits her grandmother would be left lying on her back for extended periods. She was aware of her grandmother’s wound but not its severity, with the bone being exposed.

The hospital informed the granddaughter that the wound might be infected.

She also mentioned that at the time of the interview her grandmother was still in the hospital due to the large wound on her back, which had developed at the nursing home.

This lack of repositioning and pressure relief, which are fundamental in preventing and managing pressure injuries, demonstrates the facility’s failure to adhere to best practices in wound care.

The facility even had a Wound Physician who confirmed seeing the resident’s facility-acquired sacral wound weekly. The facility however failed to implement effective interventions to prevent the wound from worsening in between the Physician’s visits.

The Director of Nursing’s confirmed that the resident had no skin assessments performed for approximately 4 weeks prior to the discovery of the unstageable sacral wound. This revelation exposes a systemic failure in the nursing home’s processes and a disregard for the safety and well-being of its residents.

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.
These systemic failures are often a sign of an understaffed nursing home. 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. 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.

IDPH has cited and fined Crestwood Rehabilitation Center for negligence in identifying, assessing, and treating a change in the resident’s skin condition that led to the development of an unstageable, necrotic (meaning death of an area of living tissue) pressure ulcer, causing unnecessary pain, suffering, and hospitalization for the resident.

Despite the resident’s care plan that stated he had the potential for impairment to his skin integrity and should be monitored for any skin injury, the facility failed to take appropriate action to prevent and detect skin breakdown.

The facility’s lack of monitoring and assessment practices allowed the resident’s pressure injury to progress to an alarming state before being discovered.

In an initial assessment of the patient a wound care physician found an unstageable pressure injury on the resident’s sacrum, measuring 9 cm in length by 9.5 cm in width. This discovery highlights the facility’s failure to identify the wound at an earlier, more treatable stage. As the wound care nurse/coordinator stated “if everyone is doing everything they should be doing, a wound should be identified before it becomes necrotic.”

The facility’s continued neglect of the resident’s wound led to further deterioration, with the sacral pressure ulcer declining to 11 cm in length by 9 cm in width, with symptoms of infection, including odor. The Wound Physician commented that the resident “needs surgical debridement and recommends he be sent to the hospital for further evaluation and treatment,” underscoring the severity of the situation and the facility’s failure to provide timely and appropriate care.

The importance of prompt identification and treatment of skin changes was emphasized by both a registered nurse and a certified nursing assistant. The RN stated, “it is important to identify skin changes right away so it does not worsen and progress to a pressure ulcer.” The RN further said “it is important to catch skin changes early to start the healing.”

The facility’s systemic failure to adhere to proper wound prevention, assessment, and treatment protocols resulted in the development of an unstageable, necrotic pressure ulcer, which ultimately required hospitalization. This lack of care subjected the resident to unnecessary pain, suffering, and risk of further complications, highlighting the facility’s inability to provide the level of care and attention required to ensure the well-being of its residents.

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.

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.

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.

IDPH has cited and fined Flanagan Rehabilitation and Health Care Center nursing home after a resident there suffered an infected bed sore which required surgery.

Bed sores are a major focus of patient care in nursing homes.  There are specific federal regulations regarding bed sores and they are a specific area of focus in the care planning process.

The Braden scale is the most common tool used to assess a resident’s risk of developing bed sores.  The resident was who the subject of this citation was assessed as being at high risk for skin breakdown when her Braden score was completed.  When a resident is at risk or high risk for developing bed sores, then the usual next step is to put a specific care plan into place to address that risk.  However, despite the fact that she was assessed as being at high risk, no care plan to prevent bed sores was put into place.

The nursing home’s policies and procedures called for daily skin inspections when a resident was at high risk for skin breakdowns.  However, during the two month period between when the resident was assessed and when she was finally sent to the hospital, only weekly skin checks are documented.

A few weeks after the initial assessment was done, the resident developed a skin breakdown over the sacrum.  The CNA who found it reported it to the nurse who notified the doctor and received orders for treatment.  Medihoney was applied to the wound and it was dressed, but there was no further documentation of the condition of the wound or of any further treatment being provided during the next month up until the resident was sent to the hospital.

The only other time there was any record of the condition of the resident’s wound was when a CNA noted the presence of a wound on a shower sheet.  The nurse on duty signed off on the shower sheet, but there was no documentation of the condition of the wound or of further physician notification.

Three and a half weeks later, the nurse found the resident unresponsive.  The physician was notified and the resident was sent to the hospital.  There, they found that she was suffering from a urinary tract infection and there was an abscess on the buttocks which was infected with MRSA.  She was diagnosed as suffering from metabolic encephalopathy due to sepsis.  The resident was brought to surgery where the wound was debrided and the abscess drained.  The surgeon described the extensive infection that was present and said that it would have been present for several days causing the resident significant pain.

There are a number of failures in the care that this resident received.  First, despite the fact that she was assessed as being at high risk for developing bed sores, no care plan to address that risk was put into place.  Second, the facility’s own policies and procedures were not followed in that the daily skin checks were not done.  Third, there was no further care provided to the bed sore once it was discovered other than the initial treatment and dressing.  Getting bed sores to heal is a lengthy process.  Fourth, there was no follow up to the wound that observed and documented in the shower sheet.  Finally, the declining condition of the wound as shown in the emergency room was not ever discovered by the staff.  Besides the skin checks that were supposed to be done daily per facility policy, the skin checks that were done during showers, the staff would have been providing incontinence care to this resident which would have offered additional opportunities to discover the decline in the condition of the resident’s skin and notify the doctor.  In short, there was a long list of failures in the care that this resident received, resulting in a serious, infected wound which required surgery.

These kinds of failures reflect poorly on the training levels of the staff and are indications that management is unwilling to invest in training the staff.  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.

Other blog posts of interest:

Failure to follow orders leads to infected bed sore at Generations Oakton Pavillion

Untreated pressure ulcer at Aperion Care Bradley

Resident develops bed sores on both heels at McLean County Nursing Home

Resident suffers from pressure ulcers at Parker Rehab

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Lexington of Orland Park nursing home after a resident there was found with a Stage 4 bed sore on her sacrum.

Bed sores are an area of intense focus in the long-term care industry for a number of reasons, not the least of which is that the development of bed sores has serious adverse consequences for the quality of life of a resident who suffers one.  Federal regulations provide that a resident who enters a nursing home without a bed sore (or pressure ulcer) should receive care, treatment, and services necessary to prevent one from occurring unless the resident’s condition shows that they are unavoidable.  The regulations also provide that after a resident develops a bed sore, they are entitled to care, treatment, and services which are necessary to promote healing, prevent infection, and prevent the development of new pressure ulcers.

It is an area which is specifically addressed during the care planning process.  It begins with an assessment of the resident, usually using the Braden scale to determine the resident’s risk level of developing pressure ulcers.  There are a number of risk factors, but they key risk factors are immobility, incontinence of bowel or bladder, and poor nutritional status.  If a resident is at risk for developing bed sores, this must be addressed in the resident care plan with steps that should be taken on a day-to-day, shift-to-shift basis.  If a resident does develop a bed sore or has a decline in an existing one, this is something that requires physician notification and revision of the care plan.

The resident at issue was admitted for short terms rehab after a fall in which she suffered a broken back with no bed sores present.  However, she was at risk for developing bed sores due to immobility associated with the fractures and incontinence of bowel and bladder.  The care plan which was put into place including daily monitoring of the skin.  Usually this is a task which is done by the aides which assisting a resident with getting dressed, bathing, or providing incontinence care.  If an aide sees an area of concern, it is the aide’s responsibility to notify the nurse who can then make a determination what it is and notify the doctor if need be.

Bed sores or pressure ulcers are rated as Stage 1 through Stage 4.  A Stage 4 is the most severe, involving exposed muscle and bone.  However, advancing from a Stage 1 to a Stage 4 takes time, and treatment can and should slow the progression, if not actually heal the wound once it is discovered.  This is why physician notification is required after a resident is discovered to have a bed sore.  Without treatment, further decline is almost a certainty.

When the staff first reported that this resident had a bed sore, it was a Stage 4 bed sore on her sacrum with sloughing and exposed bone.  In other words, this was an advanced wound, and the presence of sloughing is often associated with dead, bacteria-laden tissues which can set the resident up for complications such as cellulitis or osteomyelitis infections.  The resident was referred to a wound care doctor for treatment.

The fact that this wound was so advanced when it was first documented says that one of a number of things, but either the aides did not realize that this was a resident for whom daily skin inspections was required; they did not realize what they were looking at when they were dressing, showering, or providing incontinence care to the resident; or they did not know that skin defects needed to be reported to the nursing staff.  None of these reflect well on the quality of care that was being provided at this nursing home.

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.

Other blog posts of interest:

Infection results from failure to care for surgical wound at Arcadia Care of Morris

Oak Brook Care resident develops Stage IV pressure ulcer from immobilizer

Grove of Berwyn fails to treat bed sore

Failure to treat pressure ulcer at Franciscan Village in Lemont

Untreated pressure ulcer at Aperion Care of Bradley

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

IDPH has cited and fined Sharon health Care Willows nursing home in Peoria after a resident there developed a bed sore on his buttocks which declined to the point that it required surgery and treatment with IV antibiotics.

Federal regulations provide that when a resident enters a nursing home without having a bed sore, he should receive care, treatment and services such that the resident will not develop them unless they are clinically unavoidable.  Further, once a resident does develop a bed sore, he must receive care, treatment and services necessary promote healing, prevent infection, and prevent the development of new sores.

Because they are so specifically addressed in the federal regulations, prevention of bed sores is a specific area of focus in the care planning process at every nursing home.  The care planning process begins with an assessment of the resident’s skin condition and then their risk of developing beds sores, most often using a standardized risk assessment tool called the Braden Scale.  If a resident has bed sores or is at risk for developing bed sores, a care plan is developed which includes a series of steps that are to be taken to reduce the risk of having a resident actually develop bed sores.  That pressure ulcer prevention care plan must then be communicated to the staff who then must carry it out on a day-to-day, shift-to-shift basis.  Finally, the care plan must be evaluated on an ongoing basis to see whether it is effective in practice or whether it is meeting the care needs of the resident, taking into consideration any changes or declines in the resident’s condition.

Aides are responsible for regularly checking the skin of the residents they care for while dressing them, providing incontinence care, or giving showers. If they identify an area of skin breakdown, it is their job to alert the nurse.  Nurses are also responsible for periodic skin checks as well.  if a skin breakdown is identified, it is the nurse’s job notify the doctor of the bed sore so that the doctor can enter orders for treatment.  Further, the development of a bed sore or the decline of an existing one is an event that requires revision of the care plan.

This citation tells the story of what happens when there are multiple breakdowns in this process because staff members do not know what their responsibilities are.

When the resident at issue was admitted to the nursing home, he had no skin breakdowns.  This means that he should not have developed any unless they were clinically unavoidable.  A Braden assessment was performed which showed that he was at moderate risk for developing bed sores.  Even though the resident was at risk, no pressure ulcer prevention care plan was put into place.  A well-thought out care plan would have included a turning and repositioning schedule, use of pressure relieving device, use of barrier creams, and regular skin inspections.

Just over two weeks before the resident was sent to the hospital, an aide discovered a skin breakdown on the buttocks.  However, none of the aides reported the skin breakdown to the nurse.  The treatment nurse was responsible for doing weekly skin inspections.  However, she never identified the area of skin breakdown because the resident was in a low bed (as a fall prevention measure) making it difficult to see the area of the buttocks where the skin breakdown occurred, which was in between the folds of the buttocks.  The treatment nurse further reported to the state surveyor that the skin checks which were supposed to be done each shift by the aides was documented as being done, but were not in fact done, and on other shifts the skin checks were not completed at all.

A week before the resident went to the hospital, the treatment nurse did a quarterly reassessment of the resident’s Braden score to measure pressure ulcer risk.  This showed that the resident’s condition had declined and was now at high risk – notwithstanding the fact that resident already had a bed sore that she was unaware of.  Of course, the resident’s condition had probably declined to the point where the resident was at high risk well before that, but that did not trigger any of the nurses on the floor to suggest revision of the care plan.

Even though the treatment nurse now recognized that the resident was at high risk for skin breakdowns, she did not revise the care plan.  She expected that the care plan coordinator would revise the care plan.  The care plan coordinator acknowledged getting the Braden scores showing that the resident was now at high risk, but told the state surveyor that she didn’t know what to do with them.

On the day that the resident was sent to the hospital, the treatment nurse was helping an aide clean up the resident after an episode of incontinence.  While she was doing so, she saw two necrotic areas on the resident’s buttocks.  She alerted another nurse and they contacted the doctor who ordered the resident sent to the hospital.

T o summarize the areas where the care of this resident broke down, we have:

• The resident was assessed as being at moderate risk of skin breakdown, but no care plan was put into place.
• Multiple shifts in which skin inspections were supposed to be completed by aides which were not done or which were documented as having been done but were in fact not done.
• When the skin breakdown was discovered it was not reported to the nurse by the aide who discovered it, nor by multiple other aides during later shifts over the next two weeks plus.  Due to the failure of the aides to notify the nurses, the doctor was not notified of the skin breakdown for over two weeks, resulting in a delay in the resident receiving the care he needed.
• The skin breakdown was not noticed by the treatment nurse during her weekly skin inspections for at least two weeks, in part due to the resident being in a low bed which made seeing the wound difficult.
• The resident’s condition declined to the point that he was at high risk for skin breakdowns, yet none of the nurses recognized that this was the case so as to suggest revision of the care plan based on the change in his condition.
• The treatment nurse conducted a Braden assessment without recognizing that the resident already had a skin breakdown.
• Once the Braden was done showing that the resident’s risk of skin breakdown had increased from moderate to high risk, there was still no revision of the care plan.

So – what was the consequence of all this?

The resident was brought to the hospital, where the wounds were assessed as being Stage 4 bed sores.  Surgery was performed, and the resident was started on IV antibiotics because there was evidence that the infection of the soft tissue had worked its way into the bone (osteomyelitis).  These wounds would not have necessarily progressed to that point with proper steps being taken to prevent the bed sores or with the timely initiation of treatment for these wounds.

The failure of the aides, the treatment nurse, and the care plan coordinator to recognize what their roles are in the prevention and treatment of bed sores speaks to a nursing home which fails to invest in the training of its staff.  Unfortunately, failing to make this kind of investment in the people who work for them is common in the nursing home industry.  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.

Other blog posts of interest:

Resident suffers from multiple pressure ulcers at Parker Rehab

Bed sore requires surgery for Timbercreek resident

Flanagan Rehab resident develops infection from bed sore

Resident develops bed sores to both heels at McLean County Nursing Home

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

IDPH has cited and fined St. Anthony’s Nursing & Rehabilitation Center in Rock Island after a resident there was required to undergo surgery due to worsening in the condition of the sore.

Bed sores or pressure ulcers are a major focus of care in the long-term care industry.  The development and/or decline of a bed sore is a serious health event in the course of care for a nursing home resident, often leading to other complications.

Federal regulations relating to be sores provide that when a resident enters the nursing home, they should receive care consistent with professional standards necessary to prevent the development of bed sores.  The regulations further provide that once a resident develops bed sores, they must receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new wounds.

Once a resident develops a bed sore or a bed sore declines, two things must happen.  First, the doctor must be notified so that new treatment orders must be carried.  Second, the care plan must be evaluated and likely revised.   Both the doctor’s orders and the steps outlined in the care plan must be carried out on a day-to-day, shift-to-shift basis.

The resident at issue was admitted to the nursing home with a Stage 4 bed sore measuring 3×3.5 cm with a depth of 1.7 cm.  Over the course of a month, the wound declined in that it grew in size to 10×8 cm with a depth of 3.5 cm with necrotic tissue in the wound bed and involvement of the fascia.  At that point the resident was transferred to the hospital to undergo surgery to remove the dead tissue.

How did things go so badly for this resident?  The answer, as is often true with bed sores, was in many ways:

• The Stage 4 bed sore that he was admitted with was not addressed in the resident care plan.  In addition to physician orders, there are a number of nursing interventions that can be taken to improve the resident’s chances of healing.  Without having those steps included in the resident care plan, having those things done is left to chance.
• The physician orders were not followed.  The initial orders were for dressing changes once per day, but then were changed early in the second week that the resident was there to twice daily.  The changed orders were not reflected on the Treatment Administration Record, so the resident only got dressing changes daily – on the days that there were dressing changes at all – and there were days when there were no dressing changes at all.  Skin audits that were ordered were not done.  Measurements were not taken regularly of the wound.

Bed sores are a different kind of injury than those that might be sustained in a nursing home fall or a nursing home choking accident in that there is usually not a clearly defined time when the injury took place.  Instead this is an injury which really reflects the cumulative effects of breakdowns in the delivery of care.  The records here show that there are small breakdowns in the care happening over and over – and as a result this resident’s bed sore decline swiftly to the point that surgery was needed.

The real question is of course why these breakdowns happen, and the answer frequently comes back to this being an understaffed nursing home.  The staff in understaffed nursing homes have a hard time keeping up with basic needs of the residents, and this has a direct impact on the residents.  Unfortunately, understaffing the nursing home is a key component 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.

Other blog posts of interest:

St. Anthony’s fails to treat resident’s pain during wound care

Bed sore requires surgery for Timbercreek resident

Resident suffers pressure ulcers to both knees at Royal Oak Care Center

Resident suffers flesh-eating disease due to untreated skin tear at Regency of Sterling

Stephenson Nursing Center resident requires surgery for bed sore

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

IDPH has cited and fined Integrity of Smithton nursing home after a resident there developed a pressure ulcer on his heel which became infected and required hospitalization.

Federal regulations regarding pressure ulcers or bed sores provide that when a resident is admitted to a nursing home without pressure ulcers a resident should receive care, treatment, and services consistent with professional standard so that they should not develop them unless they are clinically unavoidable.  When a resident enters a nursing home with pressure ulcers or develops them after admission, then the regulations require that the resident receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new pressure ulcers.

When a resident is admitted to a nursing home, one of the steps in the care planning process is to assess the resident’s risk for developing bed sores, usually using a tool like the Braden scale.  If a resident is at risk for developing bed sores, then that should be addressed in the care plan.  If a resident develops new bed sores or has a decline in an existing wound, then this is something that requires physician notification to obtain new treatment orders and a revision of the resident care plan.

When this resident was first admitted to the nursing home, he was ambulatory, but then developed a pressure ulcer to his heel.  When the wound was first documented, it was listed as being an unstageable deep tissue pressure injury/pressure on his left heel measuring 6×11 cm with a 2.5×2.5 cm necrotic area in the center of the heel.  An unstageable pressure injury is one in which the base of the wound bed cannot be seen due to the presence of dead tissue in the wound.  By definition, it is considered a Stage 3 or Stage 4 wound.

The nursing home staff notified the doctor who issued orders for treatment including floating the heels from the surface of the bed and using a pressure relieving boots to help reduce pressure on the wound.  The onset of the wound coincided with the loss of the ability of the resident to bear weight on the leg, resulting in his discharge from physical therapy and occupational therapy.

A little less than 2 months after the wound developed, the wound care nurse noted an odor coming from the wound along with an increase in drainage.  These are signs of infection, and the nurse obtained an order from the doctor to send the resident to the emergency room.

There, the resident was diagnosed as suffering from osteomyelitis (a bone infection).  He was placed on IV antibiotics and underwent a surgical debridement of the wound.  If the debridement and antibiotics are not successful in resolving the infection, amputation is the likely outcome.  Either way, this resident had been significantly debilitated by the development of the bed sore.  This has led to a loss of his ability to walk and to transfer, all of which will have long-term negative effects on the quality of his life, assuming that he survives.

When interviewed by the state surveyor, the Director of Nursing claimed that the wound was a vascular ulcer and that therefore the nursing home was not responsible.  However, it was assessed as being a pressure ulcer at the outset by the nursing staff and the treating vascular surgeon also characterized the wound as a pressure ulcer, noting that vascular ulcers do not normally develop in the area where this wound occurred.

In nursing home abuse and neglect lawsuits involving pressure ulcers, the medical issues are often front and center.  Many nursing home residents have risk factors for the development of these wounds, and nursing homes often defend these cases aggressively by claiming that the wound was not a pressure ulcer or that the development of the wound was the natural progression of the underlying risk factors, i.e., that the resident was old and sick, rather than the poor care which the resident received.

Understanding the difference between the various kinds of wounds and how they develop is a critical part of being an effective nursing home abuse lawyer, and in particular how they result from the systemic poor care that nursing home resident receive.  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.

Other blog posts of interest:

Psych med usage leads to bed sores at Eastview Terrace in Sullivan

Unstageable pressure ulcer to heel at Willow Rose in Jerseyville

Police fracture skull of resident who wandered from Integrity of Smithon

Resident develops bed sores on both heels at Eden Village

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Moweaqua Rehab nursing home after a resident there suffered declines in bed sores on his heel and on his coccyx.

Bed sores, or pressure ulcers, are a major issue in the long-term care industry.  There are two basic federal regulations pertaining specifically to the topic of bed sores.  The first essentially provides that when a resident enters a nursing home without a bed sores, the nursing home should provide care to the resident such that the resident does not develop them unless they are unavoidable.  The second addresses what happens once a resident has a bed sore, and this provides in essence that a resident who has a bed sore should receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new bed sores.

Bed sores are a specific issue issue that is addressed during the care planning process.  A resident’s risk of developing bed sores is assessed, typically using a standardized tool such as the Braden scale.  A care plan is then put into place which addresses the various risk factors that are present for the resident.

The primary risk factors are immobility, incontinence, and poor nutritional status.  Immobility is customarily addressed by a turning and repositioning schedule which provides for offloading of the body and through the use of pressure-reliving devices.  Incontinence is addressed by ensuring timely care after episodes of incontinence and through the use of barrier creams.  Poor nutritional status is addressed by adding additional servings of protein with meals or providing nutritional supplements.

When the resident at issue was admitted to the facility, he was assessed as being at high risk for bed sores.  He in fact entered into the nursing home with a bed sore – a Stage 3 wound to his sacrum.  The resident chart documented that care was being provided as ordered, but the only assessments of the wound were being done on the Weekly Wound sheets.  Approximately two and half months after admission, the resident was brought to the local wound clinic where he the wound was shown to be nearly double in size and considerably deeper, with exposed muscle and eschar in the wound bed.  The wound clinic order the use of a wound vac, and also issued orders for the use of pressure relieving devices, including a specialized mattress and special wheelchair cushion,  and for turning and repositioning.  However, those orders were never incorporated into the resident’s care plan or if they were ever carried out.  The resident’s record documented that wound vac was used after it was ordered, but there was no record as to how much fluid was being removed from wound by the wound vac.  Eventually, the resident was brought to the hospital to undergo surgical debridement of the bed sore.

At the same time that the resident was receiving the orders for the wound vac for his sacral bed sore, he also developed a Stage 2 bed sore on his heel.  There was an order for the use of heel boots, but wound continued to decline and by the time that the resident was undergoing surgery for the sacral bed sores, the one one the heel had declined to the point that it was unstageable.  Unstageable bed sores are by definition at least Stage 3, but could be Stage 4 bed sore, but the presence of dead tissue in the wound bed obscures the bottom of the wound bed keeps the wound from being staged definitively as Stage 3 or Stage 4.

When the state investigator interviewed staff from the wound clinic, they were clear in their opinions: that the nursing had failed to follow the instructions that they gave, and that this led to  the deterioration of the sacral wound and the development and decline of the wound on the heel.

Bed sores present a difficult issue for nursing homes in that the residents who develop them often have pre-existing conditions which leave them susceptible to developing them.  This basic fact is actually built into the Braden Scale.  Because the medical issues that leave residents are persistent, the care that the residents require truly  has to be provided on a 24/7 basis on a day-to-day, shift-to-shift basis.  The fact that this resident saw significant declines in wounds on two areas of his body says that this care simply was not being provided as needed.

When the kind of routine care that is needed to give residents a fighting chance against bed sores is not being offered, that is a sign of an understaffed nursing home, and having an understaffed nursing home is one of the hallmarks 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.

Other blog posts of interest:

Mattoon Rehab resident dies from infected bed sore

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

Unstageable ulcer to heel at Willow Rose in Jerseyville

Moweaqua Rehab resident develops pressure ulcer from fracture brace

Psych med usage leads to bed sores at Eastview Terrace in Sullivan

Resident develops bed sore at Nokomis Rehab

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH has cited and fined Hilltop Skilled Nursing and Rehabilitation in Charleston after the staff there failed to follow physician’s orders, resulting in a resident developing a Stage 4 bed sore on her heel.

While we often discuss in this blog how important care plans are in delivering the routine care that nursing home residents need, following physician orders is also something that is mandatory.  Failing to follow physician orders can be just as devastating.

The resident at issue developed a bed sore to her left heel.  A wound care physician was brought into manage her care.  He issued orders for the care of the wound, including use of heel protectors due to her immobility.  A heel protector is something that is used to reduce the incidence of bed sores on the heels and to promote healing of any bed sores already present by reducing pressure on the skin between the bed and bony portion of the heel and by eliminating the exposure to shear.

The care provided by the doctor was effective in healing the bed sores, and when the wound care doctor discharged the patient, he included an order to continue present skin care and breakdown prevention.  This would have included the use of heel protectors because they are used as tools for both healing and prevention of bed sores.  There was never any documentation of the use of heel protectors, and the Director of Nursing admitted to the state surveyor that the heel protectors which had been ordered were not used after the wound on the heel closed.

Approximately 2 weeks later, the resident was diagnosed as having an unstageable wound to the left heel.  The wound care physician did a bedside surgical debridement and determined that after all the dead tissue was removed, that it was a Stage 3 bed sore.  Unfortunately, the wound continued to decline, requiring an additional bedside surgical debridement.  After that was completed, the resident was left with a Stage 4 bed sore on the heel – exposed muscle and/or bone.  Having a bed sore of this severity is significant for nursing home residents because it leaves the resident at greatly increased risk for an infection like osteomyelitis.

The resident’s attending doctor attributed the development of the bed sore to the failure of the staff to use the heel protectors as ordered.  Nursing homes often defend bed sore cases by claiming that the bed sores were unavoidable due to the chronic medical conditions of the resident but the statement from the physician.  The fact that this resident had sores which healed is also significant because it tends to show that there were no real biological impediments to healing which undermines the idea that the chronic medical conditions doomed this resident to suffering bed sores.

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.

Other blog posts of interest:

Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur

Resident develops bed sore at Nokomis Rehab

Aperion Care Capitol fails to obtain equipment necessary to treat bed sore

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

IDPH has cited and fined Generations at McKinley Place nursing home in Decatur after a resident there developed a pressure ulcer to her calf.

As people age, they become more susceptible to suffering fractures in falls.  At times they suffer fractures which would be repaired surgically in a younger person, but due to their surgical risk profile and lack of mobility, the course of treatment consists of immobilizing the fractures.  In the past, this would normally be done with a cast, but is more often done now with a removable device which immobilizes the fracture site allowing the fracture to heal while at the same time allowing the device to be removed to allow for skin care and to start rehabilitation.

The problem with stabilizing devices like boots and immobilizers is that by their very nature, they are intended to hold the fracture in place and as a result, create pressure.  “Bed sores” are also called pressure ulcers because one of the main factors that produce bed sores is pressure on the skin between a bony prominence (such as the hips, buttocks, heels, or tailbone) and a resting surface (such as a bed or chair).  This is why prolonged exposure to pressure as a result of immobility is one of the main risk factors for developing bed sores.  Devices such as boots or immobilizers create a risk of developing pressure ulcers in much the same way, except the pressure point is between the skin and the device.  This requires regular removal of the device and inspection of the skin for early signs of skin breakdown.

This resident was an immobilizer after suffering a broken foot.  Initially, the fracture was casted.  Then, during a follow-up office visit a small scabbed area (1×2 cm) to the back of her calf was noted, so the doctor switched her into a brace, applied a dry dressing, and ordered that the nursing home staff do daily skin checks and dressing changes.  The orders from the orthopaedic surgeon were never entered into the resident chart.  Skin checks would ordinarily be performed at the time that the resident received a shower, but this resident was exclusively receiving bed baths.  As a result, there were no dressing changes and no skin checks done.

Approximately five weeks after the resident was placed into the immobilizer, an aide reported that there was an odor coming from the resident’s leg.  When the nurse came to find out what the source of the odor was, he removed the immobilizer.  This revealed an unstageable pressure ulcer measuring 9.5 cm long, 5.5 cm wide and 1.5 cm deep with obvious signs of infection.  The resident was sent to the hospital where she underwent surgical debridement of the pressure ulcer.  The doctors there believed that the wound was caused by the immobilizer and that had the doctor’s orders been followed, the wound would not have progressed to such an extent.

Federal regulations provide that when a resident enters a nursing home without pressure ulcers, they should not develop them unless they are unavoidable.  When a resident either develops a pressure ulcer or an existing one starts to decline, this is something that requires a nurse to notify the doctor to obtain treatment orders and a revision of the resident pressure ulcer prevention care plan.  When a resident has already developed pressure ulcers, federal regulations require that they receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new wounds.

Here, the physician orders for daily skin checks and dressing changes were not followed.  Compounding this, since the resident was only receiving bed baths, she did not receive the skin checks that would happen during showers.  As a result, the progression of the wound went undetected until it became so badly infected that it was malodorous.

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.

Other blog posts of interest:

Mattoon Rehab resident dies from infected bed sore

Resident at Christian Nursing Home in Lincoln develops pressure ulcer from immobilizer

Aperion Care Capitol fails to obtain equipment necessary to treat bed sore

Resident develops pressure ulcers at Eastside Rehab in Pittsfield

Staff at Hilltop Skilled Nursing fails to follow physician orders, Stage 4 bed sore results

Psych med usage leads to bed sores at Eastview Terrace in Sullivan

Pressure ulcer from surgical boot at Amberwood Care Centre

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

 

IDPH has cited and fined Avatara of Elgin nursing home after a resident there developed a bed sore after the staff failed to take basic preventive measures after admission.

There are a handful of factors that place a resident at risk for developing bed sores.  The most prominent of these is immobility.  To combat that risk factor, putting residents who are incapable of respositioning themselves on a turning and respositioning schedule is a mainstay for pressure ulcer prevention.

The resident at issue was admitted to the facility with no pressure ulcers.  This means that under federal regulations, the resident was entitled to care, treatment, and services necessary to prevent bed sores and should not develop them unless they are unavoidable.  There are certain medical conditions which may result in a truly unavoidable bed sore.  Among these is suffering from cancer.

When the resident was admitted, he had a number of diagnoses which placed him at risk for developing bed sores, including hemiplegia (near paralysis on one side, usually the result of a stroke), malnutrition, suffered from incontinence of bowel,  and was receiving radiation therapy for prostate and bladder cancer.  These are factors which placed the risk at high risk for developing bed sores.

The resident was properly assessed as being at risk for developing bed sores, but the floor staff was advised that turning and respositioning was required for this resident.  The assessment is only the first step in the pressure ulcer care planning process.  From there, an actual care plan has to be developed and then communicated to the staff actually charged with caring for the resident.  This is an obvious point of breakdown in the delivery of care for this resident – either a written care plan was never developed or was never communicated to the staff.

The net effect?  The resident developed an unstageable pressure ulcer to the coccyx.  The wound was cultured and shown to be growing out drug-resistant organisms.  The resident was sent to the hospital for further treatment.

There was an obvious breakdown in care here which had serious consequences for a medically fragile resident.  This resident was at very high risk for developing bed sores because of the underlying medical problems he had, but was never given even a fighting chance because of the breakdown in the delivery of care.  Making matters worse, the fact that the wound culture grew out drug-resistant organisms is a grim finding because patients undergoing chemotherapy for cancer already have highly compromised immune systems.

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.

Other blog posts of interest:

Failure to care plan leads to bed sore at Avantara of Elgin

Pressure ulcer from surgical boot at Amberwood Care Center

Failure in care lead to bed sore at Park Place in Belvidere

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

IDPH has cited and fined Franciscan Village nursing home in Lemont after a pressure ulcer on a resident’s foot decline due to a lack of treatment, resulting the resident developing osteomyelitis.

Federal regulations regarding bed sores provide that after a resident develops a pressure ulcer or bed sore, they are to receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new pressure ulcers.

The development or worsening of a bed sores is an issue which requires physician notification so that the doctor can issue orders for treatment.  It also requires revision of the care plan for treatment and prevention of bed sores.  While the doctor is the one who issues the orders, in many nursing homes, the doctor defers almost entirely to the judgment of people who have been specially trained in the care and treatment of bed sores such as wound care nurses or wound care doctors.

The resident here had been under the care of a wound care doctor for a bed sore on his foot from the time of the start of this admission up until the point where his Medicare days had been exhausted, at which point, care of the bed sore was transitioned over to the primary care doctor who in turn apparently allowed the wound care nurse to manage the care of the wound.  When questioned by the state surveyor, the wound care nurse confirmed that this was the case and in any event, multiple progress notes from the primary care doctor had no notation of the condition of the wound.

Approximately a month after the wound care doctor stopped seeing the resident, the wound declined and an order for daily dressing changes and the use of a chemical debriding agent was obtained.  These orders were left in place for two months, at which time, the orders for the dressing changes and the use of the chemical debriding agent were no longer part of the monthly physician order sheets.  These orders were missing from the Treatment Administration Records for two months until they reappeared about a week before the resident went to the hospital.  The resident chart indicates that the care had stopped.

The bottom line: this resident went almost two whole months without there being any record of the daily dressing changes being done and without the chemical debriding agent being done.

This changed when another nurse noted there being a malodor to the foot and there being serosanguinous drainage from the wound on the foot.  These are all signs the wound had become infected.  The resident was sent to the hospital 10 days later where he was diagnosed with chronic osteomyelitis of the foot.

There are a number of failures which contributed to the poor outcome for this resident.  The most obvious is the cessation of treatment for the wound when the wound had not yet healed, the physician had not ordered treatment stopped, and the resident was still in need of care.  The reason for this was not made clear in the citation, but in context, it appears to be due to a clerical error in continuing orders in form month to month in the resident chart.

However, that is far from the end of the strong of failures.  The attending doctor was carrying a resident with a diagnosis of having a pressure ulcer to the foot but did nothing to actually monitor the course of care.  One of the protocols that is followed in the nursing home industry when a resident is suffering from a pressure ulcer is that there are regular (usually daily) checks done of the condition of the skin, and either none of these were being done or no one was reporting or documenting the decline of the wound until it was badly infected enough that drainage and malodor were present.

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.

Other blog posts of interest:

Failure to follow orders leads to infected bed sore at Generations Oakton Pavillion

Infection results from failure to care for surgical wound at Arcadia Care of Morris

Victorian Village resident develops pressure ulcer from orthotic boot

Untreated pressure ulcer at Aperion Care Bradley

Grove of Berwyn fails to treat bed sore

Resident develops bed sore at Avantara of Elgin

 

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

 

 

 

IDPH has cited and fined Willow Rose Rehabilitation & Health nursing home in Jerseyville after a resident there developed an unstageable pressure ulcer to the heel.

Bed sores are also called pressure ulcers or pressure sores because one of the main things that cause these wounds is pressure on the small blood vessels which supply the skin, usually from the weight of the body between a bony prominence such as the hips, heels, or tailbone against a resting surface.  One of the main strategies for combating the development of bed sores is pressure relief through the use of pressure relieving devices and a turning and repositioning schedule. Pressure relief is also a mainstay for helping nursing home residents heal from bed sores once they develop.

Federal regulations require that once a resident develops a bed sore, they receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new sores.  In order for that to happen, regular skin checks need to be performed so that once a resident develops a bed sores, the nurse can notify the doctor to obtain orders for treatment.  This also allows treatment to begin before the wound has declined to Stage 3 or Stage 4 bed sores or becomes an unstageable pressure ulcer.

The staff noted the discovery of an unstageable pressure ulcer on the resident’s heel on June 25.  The nurse on duty contacted the doctor who issued orders for treatment.  However, those treatment orders were not transcribed onto the Medication Administration Record, so the treatment orders were not carried out until July 1, when they started a new Medication Administration Record page in the resident chart.

Another part of the resident chart was the Skin Inspection Report which did not note the presence of the bed sore on the residents heel at all- even after it was noted in the chart elsewhere.

While the state surveyor was in the facility, she observed that the resident was not moved in bed for a 3.5 hour period even though her care plan called for being turned and repositioned every 2 hours.

When interviewed by the state surveyor, the resident’s doctor stated that he expected that the bed sore would have been discovered before it became unstageable.  The administrator was unable to offer an explanation as to why the bed sore was never noted on the skin inspection report and acknowledged they had trouble maintaining the every two hour turning and repositioning schedule.

As a whole, this is a facility which has a series of failures which will likely lead to more residents developing serious bed sores.  They are not maintaining the 2 hour turning and repositioning schedule, not accurately completing skin inspections, not getting orders for treatment onto the resident’s chart, and not delivering the care needed to allow residents to recover from the bed sores.  This series of failures is setting up residents for getting bed sores, letting them decline, and putting residents at risk for developing infections like cellulitis and osteomyelitis.

These kinda of failures are not a one-off event, but are happening repeatedly, which is a sign of an understaffed nursing home.  Sadly understaffing is one of the features 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.

Other blog posts of interest:

Failure to notify doctor of bed sore at Aperion Care of Moline

Resident suffers pressure ulcers to both knees at Royal Oak Care Center

Aperion Care Capitol fails to obtain equipment necessary to treat bed sore

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.