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Neglected Wound Care At Imboden Creek Leads To E. Coli Infection And Emergency Surgery

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The Illinois Department Of Health has cited and fined Imboden Creek Senior Living when the facility failed to provide basic daily wound care for a resident’s back surgery incision, skipping required cleanings and dressing changes on multiple days. As a result, the resident developed a severe E. coli infection from fecal contamination, requiring emergency hospitalization, a second surgery to clean out the infected tissue, and an extended course of powerful antibiotics.

A nursing home resident suffered a severe infection requiring additional surgery because staff failed to properly care for her surgical incision. The resident in question was admitted to the facility following back surgery (a lumbar laminectomy) that had been performed five days earlier.

The doctor’s orders were clear: staff needed to clean the resident’s surgical incision daily with normal saline, dry it, and apply a fresh dressing. They were also supposed to check the incision every shift for signs of infection. However, records show the staff failed to provide this basic wound care on multiple days.

The consequences were severe. When the resident went for her follow-up appointment, her surgeon immediately sent her to the emergency room. Hospital tests revealed a shocking discovery – her surgical incision was infected with E. coli, a bacteria found in fecal matter. As her surgeon noted, this was “a result of fecal contamination and not from surgery, consistent with the resident’s statements of poor quality care” at the facility.

The resident’s daughter described the poor care her mother received: “The nurses at the facility did not do the cleanings of her incisions like they were supposed to, the dressings they had would never stick in place, they left her on the bedpan for over an hour, she was left laying on her back almost all the time.” As a result, the resident developed “rashes under her breast and in her groin, and bed sores on her backside.”

The infection was so severe that the resident needed another surgery. The hospital records detail a gruesome procedure where the surgeon had to:
– Remove staples
– Clean out “a large amount of brown purulent material and liquid”
– Cut away infected tissue
– Perform deep cleaning through separated muscle layers
– Use multiple rounds of sanitizing solutions
– Place antibiotics directly in the wound before reclosing it

The resident required intensive antibiotic treatment, including medications that needed careful monitoring due to their strength. She had to remain in the hospital until the full course of antibiotics was completed.

This entire ordeal could have been prevented with proper wound care and basic hygiene practices. As hospital records confirmed, the bed sores and rashes the resident developed weren’t present when she was first discharged to the nursing home, highlighting how quickly her condition deteriorated under their care.

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.

Maggot Infestation Found In Resident’s Leg At Belleville Health Center

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The Illinois Department Of Health has cited and fined Belleville Healthcare Center when a nursing home resident there developed maggots in her leg wound after staff failed to properly care for her dressing changes.

The resident in question was a mentally alert woman who had an open wound on her right lower leg and needed dressing changes three times a week (Monday, Wednesday, and Friday).

The tragedy unfolded over several days. The last documented dressing change was on a Wednesday. The staff claimed they then changed the dressing two days later, on Friday, however there was no documentation to prove this, and the resident insisted it wasn’t done.

Over the following weekend, the resident repeatedly told staff something was wrong. She could actually feel movement in her wound, describing it as “creepy crawlies in her leg.” The dressing was visibly saturated with drainage, yet staff refused to help. Another resident even tried to advocate for her, telling the nurse “the dressing was saturated” and that the resident “could feel something crawling in the wound.” The nurse’s response was shocking – she told him to “mind his own business” and, according to this resident, said “it’s not due to be changed until Monday, I am not changing it” before slamming the door.

The situation came to a horrifying conclusion early Monday morning when “maggots were found in the sheets” and upon inspection, staff found “maggots within the wound bed.” The resident was immediately sent to the emergency room.

At the hospital, the situation was found to be even worse than initially apparent. X-rays showed the wound had deteriorated significantly, with “severe soft tissue swelling” that now “extends through to the underlying fibula” (leg bone). The resident had developed osteomyelitis (bone infection) and her wound tested positive for multiple serious infections including MRSA.

As a result of this negligence, the resident required:
– Hospitalization
– Treatment for maggot infestation
– 42 days of intravenous antibiotics for multiple infections
– Treatment for bone infection

The Director of Nursing later admitted that staff should have responded when the resident complained: “she would have expected her nurse to remove the dressing and assess the wound when the resident complained of discomfort.” The facility eventually moved the resident to a different room, as her previous room’s location near the smoking area meant there were “more flies in the resident’s previous room.”

This incident violated the facility’s own policy which required staff to check dressings for drainage and the presence of possible complications. As the hospital notes stated, the resident “states dressing is to be changed every MWF (Monday, Wednesday, Friday), but staff hadn’t changed since last Wednesday.” The consequences of this negligence led to a serious deterioration in the resident’s condition and weeks of intensive medical treatment.

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.

Facility’s Failure To Adequately Care For Bruise Sends Resident To Hospital With Septic Shock And Left Foot Abscess

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IDPH has cited and fined Accolade Healthcare Danville when the facility failed to properly assess, monitor, and report a bruise/hematoma on a resident’s left foot, which ultimately led to a serious infection requiring hospitalization and surgical intervention.

The incident in question began when a “fresh, purple bruise” measuring 3 cm by 1 cm was discovered on the resident’s left foot. The resident reported that it likely occurred during a mechanical lift transfer the previous day.

Initial documentation and monitoring of the bruise were inconsistent and inadequate. While a Weekly Skin Assessment noted the bruise had grown to 5 cm by 2.5 cm, subsequent assessments on the following two consecutive weeks failed to mention the bruise at all, stating only that there were “no new or worsening skin conditions.”

The facility’s failure to properly monitor and report the worsening condition led to severe consequences. Approximately two and a half weeks after the initial reporting of the wound, the resident was hospitalized with “left foot swelling, fluctuance (boggy feeling due to buildup of fluid), redness and warmth.” The hospital diagnosed the resident with septic shock and a left foot abscess. The situation was so severe that a few days later, “purulence was expressed from the resident’s abscessed hematoma and a large hematoma was operatively removed.”

Upon the resident’s readmission to the facility, further lapses in care were evident. The readmission assessment noted “multiple stage one pressure ulcers on the right outer foot” without providing crucial details such as the number of wounds, their characteristics, or measurements. Subsequent assessments continued to lack necessary detail and consistency.

The facility’s staff, including nurses and wound care specialists, acknowledged these failures in care. A RN stated that “the area stayed the same from when it was first identified until the resident was hospitalized, and the area had not shown any signs of improvement.” The same RN also noted that “there should be documented monitoring and assessments for this area recorded on the Treatment Administration Record or progress notes,” which were clearly lacking.

A Nurse Practitioner emphasized the severity of the oversight, stating that “the facility staff should have been monitoring and assessing the resident’s hematoma, including characteristics, measurements/assessments, and monitoring for fever.” The Nurse Practitioner added that “it is a ‘strong possibility’ that the resident’s hospital incision and drainage may have been prevented if the resident was evaluated by the Wound Physician and antibiotics were ordered.”

The Wound Physician corroborated this assessment, stating that had the facility properly monitored and reported the hematoma, he “would have lanced and drained the hematoma at the facility, which could have prevented the resident’s hospital incision and drainage.”

This case highlights a systemic failure in wound care protocols, communication, and adherence to established policies, resulting in unnecessary suffering and complications for the resident.

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.

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

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IDPH has cited and fined Arcadia Care of Morris nursing home after a resident there developed an infection of a surgical wound for a hip fracture, requiring IV antibiotics and a surgical debridement.

The resident at issue was admitted to the nursing home for post-operative care after suffering a broken hip in a fall.  There was a surgical wound incision that had been closed with staples, and the resident was supposed to be seen in the surgeon’s office for removal of the staples in 1-2 weeks.

That didn’t happen – because the nursing home staff seems to have failed to recognize that there was a surgical wound, despite the fact the resident was being admitted for post-operative care.

When a resident is admitted to a nursing home from a hospital, there are a number of steps that must be taken.  One of these is to take the discharge instructions and orders and have them added to the resident’s chart with the resident’s attending physician giving orders for care.  This helps assure continuity of care – that the resident continues to get the care in the nursing home that the doctors in the hospital wanted them to get.  The order is a head-to-toe inspection of the resident’s skin.  Part of this is to ensure that the resident is not arriving at the nursing home with bed sores that the nursing home might otherwise be blamed for, but also to ensure that if there is some defect in the skin, that proper orders are obtained for caring for that.

When this resident was admitted to the nursing home, that comprehensive skin assessment was apparently not done, as there was no documentation of that.  There were also no orders for wound care obtained from the resident’s physician.  The resident’s 1-2 week follow up appointment was not set.  The resident care plan, which is supposed to address all of the risks to the health and well-being of the resident, did not address wound care.  A single note, done a month after admission by the wound care nurse, documents that there was no injury to the skin.

Two days after the note was generated by the wound care nurse, and more than five weeks after the surgery, the resident was brought to the orthopaedic surgeon’s office.  He removed the staples and sent the resident to the hospital because there was evidence that the surgical wound was infected, likely due to the length of time that the staples were left in place and the lack of dressing changes.  The resident was admitted to the hospital to get IV antibiotics for the infection and to have a surgical debridement done of the infected tissue.  The orthopaedic surgeon told the state surveyor, “I have had problems with that facility lately and am thinking of mot letting my patients go there anymore.”

There were a number of failures in the care that this resident received.  First, there was a basic breakdown of the systems which assure continuity of care.  Second, the admitting nurse and almost every nurse after that failed to assess the wound or recognize that treatment was not being provided for it.  Third, residents’ skin is normally checked by aides during baths or showers and defects are reported on “bath sheets”.  Either this was not done or no action was taken with regard to that.  Fourth, the care planning process is intended to be a comprehensive review of the resident’s care needs, and yet, in the process of doing the care plan, the need for wound care and skin assessments was completely missed.  The net result of this is that the resident suffered a surgical wound infection, which can be a very grim condition indeed if it requires removal of the orthopaedic hardware.  Yet, this is the risk that this resident is being subjected to due to a lack of basic care provided here.

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:

Flanagan Rehab resident develops infection from bed sore

Surgical wound infection at Regency of Morris

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.

Failure to obtain treatment orders leads to infection of surgical wound at Loft of Canton

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IDPH has cited and fined the Loft Rehab & Nursing of Canton nursing home after a resident there developed a surgical wound infection due to the failure of the staff to obtain orders for the care of the wound.

Many persons who undergo surgery are sent to nursing homes for post-operative rehabilitation.  Often part of the care is actual rehabilitation – therapy that is needed to get them “back on their feet” so that they can go home.  However, a crucial part of the care that residents receive is directed toward making sure that residents receive necessary medications and lab work, that the surgical incisions are healing and free of signs of infection, and other aspects of care that are directed to making sure that nothing goes awry.

When residents are admitted to the nursing home from a hospital, there are transfer orders that go with the resident.  Typically these will include things like the medications the resident is supposed to receive, treatments that the resident requires, labs that must be completed, and so forth.  This assures continuity of care.  When the resident is being admitted the nurse at the nursing home is supposed to review the orders with a nurse from the transferring hospital.

Additionally, when the resident is admitted to the nursing home, they undergo a number of assessments, one of which is a head-to-toe skin inspection.  One of the reasons for the skin inspection is to check for the existence and condition of any bed sores or pressure ulcers.  However, in the context of a post-surgical admission, this inspection is to check to see if there are signs and symptoms of infection to any of the wounds and to make sure that there are appropriate orders for care of the surgical wounds.

The resident at issue here was initially admitted to the nursing home after undergoing the removal of her parotid glands and a resection of her neck due to malignancy.  However, she developed a post-surgical infection and had to be readmitted to the hospital.

When she returned to the nursing home, there were four surgical wounds present, including one which under her left breast but which was recorded in the chart as being a “chest” wound.    That “chest” wound included a drain, staples, and a surgical dressing.  However, there were no orders for the care of that surgical wound, and no one called the doctor or the hospital get orders for care.

As a result, the resident was in the nursing home for a week with no care being provided for the wound under her left breast.  This continued until the surgical wound developed an odor, was red and inflamed, and was draining yellow and green fluid.  The resident was also lethargic, said that she was not feeling good and having nausea.  These are all signs of infection.  The resident was brought to the hospital where the dressings were changed and the resident was placed on antibiotics.  The surgeon also ordered a culture of the wound.  When the cultures were completed, they showed that the wound to the breast as well as wound on her clavicle were infected with MRSA.  The resident was sent back to the hospital for management of the new wound infections.

There were a number of shortcomings in the care that this resident received:

  • It is unclear from the citation whether the “chest” wound recorded on the admitting assessment referred to the clavicle wound or breast wound.  If the breast wound was missed all together, that is a complete failure on the skin inspection;
  • There were very clearly no orders for the breast wound.  When the skin inspection revealed that there was a breast wound for which there were no treatment orders, it was incumbent upon the nursing home staff to contact the doctor for treatment orders, just as physician notification is required when a resident develops a bed sore;
  • After the resident was admitted, there were multiple shifts where no one seemed to recognize that there were no orders for the treatment of the breast wound.  Multiple opportunities missed.
  • Typically, the condition of a post-operative wound is recorded on a per shift basis.  This is because a surgical wound infection is a serious matter which needs to be addressed promptly.  The condition of the dressing when the nurses first noted the odor was described as being filthy, which means that there had likely been multiple shifts where either no one paid any attention to the breast wound or to the fact the dressing had not been changed.

In short, there were several levels of failure at the nursing home in the care of this resident, all of which led to a serious infection of the surgical wound.  The resident had been admitted to the hospital for care for this, but this will likely require extensive use of antibiotics and likely surgical excision of the infected tissues.  This is a situation which was made worse, not better by the care that this resident received.

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:

Heartland of Galesburg resident dies due to untreated urinary tract infection

Rushville Nursing & Rehab resident suffers untreated surgical wound infection

Failure to notify physician leads to resident death at Alden Estates of Barrington

 

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

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

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IDPH has cited and fined Regency of Sterling nursing home after a resident underwent surgery for a infected skin tear which had not been treated while at the nursing home.

One basic fact of life is that as we age, our skin gets thinner and more susceptible to injury.  This is why bed sore prevention is a focus of care in nursing homes.  With senior citizens, one form of injury to the skin that they are susceptible to skin tears.  A skin tear is a traumatic injury to the skin which results in the separation of the skin, frequently with peeling back of the skin.

Most often skin tears can be treated relatively easily by bringing the edges of the skin together and using steri-strips and dressings to promote healing of the wound.  However, as with any wound, the occurrence of a skin tear is something that requires physician notification and ongoing monitoring for healing and signs and symptoms of infection is absolutely required.  Intact skin is the most effective barrier to having infecting organisms enter the body, and having a skin tear is a breach of the integrity of the skin.

The resident at issue sustained a skin tear to her left lower outer leg while being assisted into bed by staff.   The resident had been recognized as being at risk for skin tears, and care should have been taken by the staff to avoid injury to the skin in transferring the resident to bed.

Once a skin tear occurs, the staff is then required to care for it properly and monitor for signs and symptoms of infection.  This nursing home had specific policies and procedures in place which were intended to set forth what should be done in the event of a skin tear.  These required notification of the physician after a skin tear occurs to obtain treatment orders, following the wound orders, and ongoing monitoring by the wound care nurse.  In practice the wound care nurse would do rounds on patients with wounds weekly and she would be notified by the nursing staff that there was a new patient with a wound that required care.

The first problem that occurred here is that the first step – notifying the physician and obtaining treatment orders never happened.  There was no record in the chart of the physician being notified.  There were no orders from the doctor recorded in the resident chart.  The resident was not added to the roster of patients who required care from the wound care nurse.  The Treatment Administration Record did not show that there was monitoring of the wound or care being provided.  The basic steps to initiate care were simply not taken.

The facility policies called for an incident report to be completed – and it appears from the text of the citation that an incident report was in fact completed.  However, in a well-run facility, incident reports are more than paperwork which is finished.  They should be a catalyst for the administration to investigate and make sure that proper follow-up was being done.  The records of this resident seem to indicate that was not the case here.

The failures of the nursing home in this case do not end there, however.  Even with a wound care nurse on staff, this does not absolve the nurses and staff on the floor of their responsibility to serve as the “eyes and ears” of the doctors and to notify the doctor when a resident is demonstrating signs and symptoms of an infection.  Nurses do not need to know how to treat an infection, but they do have to be able to recognize the signs and symptoms, which can include: fever, redness and warmth of the affected area, blistering of the skin, drainage, and changes in mental status, among other signs.

Five days after the resident sustained the skin tear, the resident demonstrated increased confusion.  After the nurse on the floor did an assessment, she paged the on-call nurse practitioner who ordered the nurse to call 911 and have the resident sent to the emergency room.

Once the resident was brought to the emergency room, her temperature measured 102.6 degrees.  Her leg showed large fluid filled blisters from her ankle up to mid calf with tenderness and red and blue discoloration.  The infectious disease physician diagnosed her as suffering from necrotizing fasciitiis, or flesh-eating disease.  He recommended antibiotics and immediate surgical debridement.

There were a number of issues with the care that this resident received:

  • Depending on the facts and circumstances, the skin tear itself could be evidence of improper technique or potential understaffing of the nursing home;
  • There was no notification to the doctor or even the wound care nurse, which resulted in inadequate treatment and monitoring of the wound;
  • There was no follow-up to the incident report which was generated concerning the incidence of the skin tear;
  • There was inadequate care by the staff on the floor after the skin tear occurred, as there were likely signs and symptoms of the infection days before the nurse practitioner was notified;
  • There were multiple violations of facility policies and procedures.

All of these failures together led to the resident experiencing a devastating infection which will require significant medical care, all of which could and likely would have been avoided with routine follow-up care to the kind of injury that happens fairly frequently in a nursing home setting.  Simple steps not taken led to disaster.

One of our basic 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:

Lack of wound monitoring leads to infection at Regency Care of Morris

Fall leads to brain bleed and death at Regency Care of Sterling

Heartland of Moline resident develops pneumonia due to failure to follow diet orders

 

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

 

 

Rushville Nursing & Rehab resident suffers untreated surgical wound infection

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IDPH has cited and fined Rushville Nursing & Rehabilitation Center nursing home after a resident there suffered significant complications from an untreated surgical wound infection.

One of the common reasons that people are admitted to nursing homes is for rehabilitation after a hospitalization.  This may include post-surgical care.  One of the basic functions of the nursing staff in caring for residents who are admitted for post-surgical care is to monitor for signs and symptoms of infection.  Signs and symptoms of infection may include abnormal white blood cell counts; foul-smelling purulent drainage (pus); fever; redness and warmth around the surgical site; the presence of slough and necrotic tissue; confusion; increased respiratory rate and pulse; and low blood pressure.

Nurses do not need to know how to treat an infection – that is for the doctors to determine.  However, because doctors are not present in an nursing home 24/7, the nursing staff is the “eyes and ears” of the doctors and must notify the doctor when signs and symptoms of infection are present.  The doctor then can decide to come to the nursing home himself to treat the patient, issue orders over the phone, or order the resident sent to the hospital to receive care there.

The resident involved was admitted to the nursing home after undergoing a complicated abdominal surgery which resulted in multiple surgical wounds, the placement of abdominal mesh, a surgical drain, and the need for the use of a wound vac.  However, there was no evidence of a wound infection at the time the resident was admitted to the nursing home, and the day before the resident was transferred, her lab work showed that there was a normal white blood cell count.  The orders were for dressing changes every Monday, Wednesday, and Friday and to return to the wound care clinic two weeks later.

The first 10 days after the resident was admitted to the facility were relatively unremarkable.  However, two days before she was to go to the wound clinic, the floor nurse noted a very foul odor to the would.  She notified the wound care nurse, who was scheduled to see the resident and do a dressing change that day.  The wound care nurse noted tunneling in the surgical wound, purulent drainage, a foul odor, reddened skin on the edges of the wound, moderate slough and necrotic tissue.  These were obvious signs of infection.  She faxed a note to the doctor’s office asking for an order to give an antibiotic.  In response, the physician’s nurse practitioner called and asked the floor nurse to check for warmth around the edges of the wound.  The floor nurse reported back that there was no warmth present, so the nurse practitioner decided to assess the wound herself the following day.

When the nurse practitioner arrived the following day, the wound vac and dressing were in place.  She chose to not take down the wound vac and the dressing to assess the wound itself. Seeing no signs of infection on the exterior and with the resident not running a fever, she decided to let the wound clinic address things when the resident went in for her appointment the following day.

The next day, the resident had her scheduled appointment with the wound care clinic.  However, when the transportation aide arrived in the resident’s room to take her to her appointment, she discovered that the resident was not dressed and could not be make the scheduled time at the wound clinic.  The staff told the aide that they did not get the resident dressed because they were unaware of the appointment at the wound clinic.  The clinic advised that they could not get her in later that day, so the appointment was rescheduled for five days later.  Later that same day, lab work for the resident showed an elevated white blood cell count.

Three days later the notes in the resident’s chart show that there was a foul odor and slough in the wound bed with edges of the wound being reddened.  However, there was no notification of the doctor of this.  The following morning, there as foul smelling drainage coming from the drain, but the doctor was not notified.  That evening, there was additional foul-smelling drainage from the drain, so the nurse on duty faxed a note to the doctor’s office after hours.

The next day was the rescheduled appointment at the wound clinic.  That morning the staff at the nursing home noted that the drain was producing thick, brown drainage.  The nurse practitioner was in and noted that the fax the day before had been received after hours and that the resident was scheduled to go to the wound clinic later that day.

On arrival, the staff at the wound clinic noted that the resident did not look well.  They took her blood pressure and found that it was low.  Inspection of the wound revealed that the abdominal wall had separated and that there was fecal matter in the wound and draining into the drain.  They concluded that the wound was badly infected and had the resident transferred to the hospital.  The nurse practitioner at the wound clinic later told that the state surveyor that the wound had not been cared for appropriately at the nursing home and that the wound did not deteriorate to that extent overnight.  She also said that the nurse practitioner at the nursing home told her that the staff at the nursing home did not tell her of the extent of the deterioration of the wound and that she had only looked that he exterior of the wound with the wound vac and dressings still in place.

At the hospital, lab work showed that the resident’s white blood cell had increased further.  She was diagnosed as suffering from low blood pressure, a necrotic wound of the abdominal wall with surgical site dehiscence, fecal matter draining into the surgical wound, and an intrabdominal infection.

As a general proposition, early intervention with an infection yields better outcomes.  There were a number of times when earlier intervention would have been appropriate, but the infection went unchecked for a week after the first signs of infection were present.  This allowed the infection to spread and worsen.  This resident will likely have to undergo multiple surgeries to try to resolve this infection and undergo a lengthy course of antibiotics.  Once the infection is clear, there will likely be extensive surgical wounds which will be difficult to close, leaving this resident at risk for further infections and complications.

There are a number of places where earlier action should have been taken which would have led to an improved outcome for this resident:

  • When the floor nurse first recognized that there was a foul odor to the wound, this was a sign of infection.  This in itself required physician notification, not just referral to the wound care nurse.  The wound care appropriately asked for an order for antibiotics.  The nurse practitioner should have likely given the order.  However, the content of what was communicated to the nurse practitioner is important because it was apparently not enough to justify a phone order for the necessary antibiotics.  Nurses need to communicate enough information to provide a basis for medical decision-making.
  • When the nurse practitioner came in the following day, she assessed the wound without taking down the wound vac and the dressing, making it impossible to see what was actually underneath.  This deprived her of vital information for her decision-making.  The supervising physician for the nurse practitioner reportedly told the administrator that he did not condone the practice of trying to assess the wound without removing the wound vac and dressing.
  • On the day of the scheduled appointment, the resident was not dressed and ready to go resulting in the cancellation and rescheduling of the appointment.  The resident was not ready to go because the staff was reportedly not aware that she had an appointment.  Getting residents to scheduled doctor appointments is a basic function in providing care in this setting.  There was a clear breakdown in that process.
  • Once it became apparent that the resident was not going to make the appointment as scheduled, the urgency of the resident being seen was not communicated to the wound care clinic.  The staff already had concerns about the resident having an infection and part of the thought process for the nurse practitioner the day before had been that there was a pending wound care clinic appointment.  When that was not going to happen, the clinic needed to know that there was some urgency for them to see the resident, and why.
  • During the days leading up to the rescheduled wound clinic appointment, the resident doubtless continued to show signs and symptoms of infection, most of which were not noted by the staff.  The few times that there notes suggestive of the presence of infection, there was no notification to the doctor until the after-hours fax was sent the evening before the rescheduled appointment.  When a resident is demonstrating the kind of advanced signs of infection that this resident was showing, simply faxing a note over was not sufficient – a call or page was required.  Why?  Because we know that no one responded to the fax sent the evening before – resulting in additional delay and spread of the infection.

There were multiple missed opportunities to drive a better outcome for this resident, spread across several days and several health care providers, including the nurse practitioner.  The net result is that this resident will experience significant, needless suffering and complications.

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:

Heartland of Galesburg resident dies due to untreated urinary tract infection

Aperion Care of Wilmington resident suffers ruptured colon due to fecal impaction

Failure to notify physician leads to resident death at Alden Estates of Barrington

Failure to adequately report changes in condition at Heritage Health in Carlinville

 

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

 

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