Pekin Manor Fails to Prevent Severe Pressure Ulcers in Three Residents

The Illinois Department of Health has cited and fined Pekin Manor when the facility failed to implement proper pressure ulcer prevention measures for three residents, resulting in severe stage four pressure ulcers that required surgical debridement. The facility’s failures included not conducting required risk assessments, not providing ordered pressure-relieving equipment, and not following physician treatment orders, causing unnecessary pain and suffering for vulnerable residents.

Pekin Manor had established comprehensive policies for preventing pressure ulcers, stating that “measures are taken to prevent skin breakdown” and requiring that “a skin assessment (Braden Scale Pressure Ulcer Risk Assessment) is completed on all residents upon admission and weekly for the first four weeks after admission, quarterly, and whenever there is a change in the resident’s condition.” The policy also mandated that “all high and moderate risk residents will be assessed for the needs” of special equipment including “special mattress and wheelchair cushions,” “turning and positioning schedule,” and “elbow/heel protectors/bridging of heels.”

However, the facility systematically failed to follow these policies for three residents, leading to preventable and serious injuries.

The first resident was an elderly woman admitted with muscle weakness, lack of coordination, and vascular dementia. She was assessed as being at risk for pressure ulcers and required moderate assistance with personal care and repositioning. Despite this risk status, the facility failed to conduct the required quarterly risk assessments, with her medical record showing “only had one Braden Scale Pressure Risk Assessment done within the last year” when she “should have had Braden Scale Pressure Risk Assessments done quarterly.”

More critically, the facility failed to implement basic pressure-relieving interventions for this resident’s heels, leading to a severe stage four pressure ulcer on her right medial heel that required surgical debridement. The Director of Nursing admitted that the resident “did not have any pressure relieving interventions to the heels prior to the development of the pressure ulcer to the right heel” and that “pressure relieving heel boots are not on the care plan.”

When health inspectors visited, they found the resident sitting in her wheelchair and the resident “did not have heel protecting boots on, or a dressing covering the right outer heel wound.” The following day, inspectors observed her “lying on a low air-loss mattress” with “heels lying directly on the bed” and “did not have pressure relieving heel boots on, or her heels off-loaded as ordered by the physician.” Even more concerning, a certified nursing assistant “verified he did not know the resident was supposed to wear heel protector boots,” demonstrating a complete breakdown in communication and care coordination.

The wound physician’s assessment revealed the severity of this preventable injury, documenting a “stage four pressure wound of the right medial heel full thickness” measuring “5.0 cm by 5.3 cm” with “moderate serosanguinous drainage” and requiring “surgical excisional debridement procedure to remove necrotic tissue.”

The second resident, a man in his late nineties, suffered even more extensive injuries. He was admitted with multiple conditions including reduced mobility and joint stiffness, making him particularly vulnerable to pressure ulcers. Like the first resident, he did not receive required weekly risk assessments after admission, with his medical record showing “does not include any Braden Scale Pressure Risk Assessments weekly times four weeks after admission, or quarterly except for the one assessment” completed much later.

This resident developed two severe pressure ulcers – one on his left lateral ankle and another on his right lateral heel – both progressing to stage four severity requiring surgical debridement. The ankle wound became infected with dangerous bacteria including MRSA (Methicillin-Resistant Staphylococcus Aureus), requiring antibiotic treatment. The wound physician documented the infected ankle wound as having “moderate serosanguinous” drainage with “80% slough” and “20% granulation tissue.”

The facility’s treatment failures compounded the resident’s suffering. Treatment records showed that “treatments to the right lateral heel pressure ulcer and left lateral ankle were not performed” on at least one day when they were scheduled. The Director of Nursing acknowledged that “treatments to the left lateral ankle and right lateral heel were not done as ordered” and that the resident “did not have pressure relieving interventions to the heels or ankles prior to developing the pressure ulcers.”

The third resident, a woman in her early nineties with dementia and a fractured femur, developed a pressure ulcer on her right ischium (hip bone area) due to similar systemic failures in care. She was assessed as being at risk for pressure ulcers and required maximum assistance with turning and transfers. However, her medical record showed “does not include any Braden Scale Pressure Risk Assessments weekly times four weeks after admission, or after a change in condition except for the one assessment” completed upon admission.

When this resident developed her pressure ulcer, the physician ordered specific interventions including a “low air loss mattress” and instructions to “off-load wound, reposition per facility protocol, turn side-to-side in bed, and float heels in bed.” However, the facility failed to implement these orders. Health inspectors found her “lying in bed on her back, on a regular mattress (not low air-loss as ordered by the physician)” with “heels lying directly on the bed” and “did not have heel protection boots on, or her heels off-loaded as ordered by the physician.”

The Director of Nursing admitted she was unaware of the physician’s orders, stating “I do not know if the resident’s heels should be off-loaded or if the resident is supposed to have a low air-loss mattress or heel boots. I will have to look at the resident’s orders.” This statement revealed a fundamental breakdown in care coordination and communication.

During wound treatment, inspectors observed the resident “was moaning and saying ouch” when her dressing was removed, demonstrating the pain these preventable wounds caused. The wound nurse acknowledged the facility’s failures, stating “I did not get the resident a low air-loss mattress or pressure relieving boots” and “the resident’s air-loss mattress and pressure relieving boots never got added to the resident’s care plan.”

The wound physician who treated all three residents confirmed that these injuries were most likely preventable, stating that the facility “should always off-load the resident’s heels to prevent pressure to the heels” and verifying that all three residents “should have had pressure relieving interventions tried prior to development of pressure ulcers to prevent their pressure ulcers from developing.”

These cases demonstrate a systematic failure to protect vulnerable residents from preventable harm. Despite having comprehensive written policies, the facility failed to conduct required risk assessments, implement basic pressure-relieving interventions, follow physician orders, and ensure staff were aware of residents’ care needs. The consequences were severe – three residents suffered painful, infected wounds requiring surgical treatment, with lasting effects on their health and quality of life. The wound physician emphasized the seriousness of these injuries, noting that stage four pressure ulcers represent “full thickness loss of skin” with tissue damage extending deep into underlying structures.

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.