Goldwater Care Danville Cited After Resident Developed 18 Pressure Sores

The Illinois Department of Health has cited and fined Goldwater Care Danville when a completely dependent resident developed 18 separate facility-acquired pressure sores over nine months, including five Stage 4 ulcers, due to staff failing to reposition him, provide basic care, follow treatment orders, and prevent infections. Staff repeatedly failed to turn the resident for hours at a time, cross-contaminated his infected wounds during dressing changes, and took days to implement physician orders, resulting in severe wounds requiring surgical debridement and antibiotic treatment for sepsis.

The resident in question was admitted with Parkinson’s disease and vascular dementia. His assessment showed he was severely cognitively impaired and completely dependent on staff for all care including eating, toileting, dressing, and bed mobility. He was assessed as high risk for developing pressure ulcers.

The resident’s power of attorney explained: “The resident was admitted in November and was still walking in January. The facility let him walk all day and ‘never changed’ (provided incontinence care), which caused his first pressure ulcer in January. The resident has had multiple facility-acquired pressure ulcers since January, all caused by facility staff not turning and positioning him timely.” The family member visits daily and “sees every day that the staff wait three to four hours before coming into the room to reposition him or to check if he is incontinent.”

Over the following months, the resident developed 18 separate facility-acquired pressure ulcers on his buttocks, sacrum, hips, knees, shins, and ankles. The wound physician stated the resident “has had a total of 18 facility-acquired pressure ulcers since the beginning of the year” and that “several pressure ulcers resolve, which shows the resident has the potential to heal his wounds.” However, the physician stated the facility “lags behind” in getting interventions and orders in place, and “when the facility finally catches up, the resident’s wounds begin to heal.” The physician emphasized this lag “shows that the facility is not doing their job and that it takes a negative toll on the residents affected.”

Observations revealed serious failures in basic care. During one observation, the resident was in his bed from 10:05 AM to 2:45 PM without being repositioned or provided incontinence care. At another meal, the resident “was not served double portions of protein as ordered by the physician” despite orders requiring this to support wound healing.

Staff also contaminated the resident’s infected wounds during dressing changes. During one observation, a nurse was “standing in front of the room air conditioner that was blowing air, which caused her gown to make contact twice with the resident’s sacrum Stage 4 pressure ulcer.” The nurse “used her left gloved hand to push her gown off the sacral pressure ulcer and then continued to complete the wound dressing change without washing her hands or changing gloves.”

Another nurse “released her hold on the resident, which caused the resident’s sacral Stage 4 pressure ulcer to touch his contaminated incontinence brief.” The first nurse then “applied the sacral dressing without cleansing the sacral Stage 4 pressure ulcer after the wound made contact with the incontinence brief.” The nurse later admitted she “should have changed her gown and re-cleansed the sacral wound” and acknowledged that “cross-contaminating open pressure ulcers could cause an infection or worsen his current wound infection.”

The consequences of this lack of care were severe. The resident eventually developed a fever with “strong odor coming from the wound as well as increased drainage.” Hospital lab results showed over 100,000 colony-forming units of bacteria. Hospital records documented he “underwent excisional debridement of his infected sacral decubitus and left ankle wounds” and “was treated for sepsis due to an infected decubitus ulcer.” The family member described: “The wound physician had to ‘cut all the dead skin’ off the sacral wound, and the hospital then took him into surgery to remove the rest. The sacral wound ‘smelled horrible from outside the room.'”

There were systematic failures in following physician orders. The wound physician stated he “was under the impression that the director of nursing was reviewing and entering his wound orders into the electronic medical record the same day” but stated “it is not acceptable for the facility to wait two, three, or four days for changes in wound orders to be entered.”

Staff confirmed this problem. One nurse stated “the floor nurses do not look in the miscellaneous tab and search through pages of wound progress notes.” The director of nursing acknowledged the wound physician’s “wound progress notes are located in the miscellaneous tab and are not added to the physician order sheet until a nurse completes her review of all resident wounds on Wednesdays” – meaning orders could sit unimplemented for days.

The resident’s care plan also failed to include several of his Stage 4 pressure ulcers and did not include a turning schedule despite being completely dependent and at high risk for pressure ulcers.

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.