IDPH has cited the nursing home Carriage Rehab & Healthcare in Rockford, IL after they failed to follow doctor’s orders for the bedsores of not one but two residents.
Bedsore care and treatment are supposed to be a top priority at long-term care facilities. Also known as pressure sores, these lesions or wounds are anticipated among residents who have reduced mobility, as they tend to stay in one position for long periods of time. We have federal regulations that entitle nursing home residents to proper care that promotes the healing of existing bed sores, prevents their infection, and prevents the development of new ones.
When a resident develops a bedsore, the nursing home staff is required to notify the doctor, and the doctor then enters orders for treatment. These treatment instructions typically have to be carried out by the staff on a daily basis. Haphazard treatment for bed sores could lead to worsening wounds and serious infection of surrounding tissues.
In this case at Carriage Rehab, one resident had a bedsore on her heel, and another resident on the side of her foot. The wound care doctor ordered daily dressing changes for each of them. It is standard procedure to write the date of the dressing so that people know when it was last changed.
As the doctor was making his weekly rounds, he discovered that the dressing on one resident had been left unchanged for an entire week, as indicated by the date on it. The next week, he found that the same had happened to the other resident.
The doctor went to the nursing home administrator to explain that this was unacceptable and needed to be reported to the State of Illinois.
The two residents had to undergo debridements or the removal of dead tissue from their wounds. This process would likely have been unnecessary if their bedsores were encouraged to heal with daily dressing changes. Likewise, the prolonged pain of these residents might have been mitigated had the nursing staff followed the doctor’s instructions.
It speaks volumes that the doctor’s orders were skipped not just for a couple of days but for a whole week, and in two separate cases within the same facility. Citations like this are strong indicators of the quality of care that each individual resident receives in a nursing home.
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