IDPH has cited and fined Mattoon Rehabilitation & Healthcare Center nursing home after a resident there died due to a bed sore that developed in the nursing home and 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.
There are a number of factors which place a resident at risk for developing bed sores. The most common are immobility, incontinence, and poor nutritional status. There are other factors as well, and these are wrapped into an assessment tool known as the Braden Scale, which measures the resident’s risk of developing bed sores.
When this resident was admitted to the nursing home, she did not have a skin breakdown on her sacral area and was assessed as being at moderate risk for skin breakdown. The citation does not describe a care plan having been created to address the resident’s risk of developing bed sores. Since the resident was at risk, there should have been one created. Some of the common steps would have included a turning and repositioning schedule to relieve pressure on the resident’s skin. It should have also included a plan for prompt incontinence care as the chemicals in urine and feces as well as the associated moisture contribute to the breakdown of the skin. These steps were necessary because the resident was dependent on the staff for bed mobility and toileting.
The resident’s record reflected that during 31 days she was in the nursing home, she was toileted two or more times on only 12 days. During the first three weeks the resident was in the facility, she was only bathed twice. This lack of incontinence care means that the resident’s skin was being subject to breakdown from urine and feces. This was consistent with the observations of the family who told later treating health care professionals that the resident was often soaked in urine.
Nine days after admission, the resident was first identified as having a skin breakdown. When a skin breakdown occurs in a nursing home resident, this is a change in condition requiring physician notification. The purpose of notifying the doctor is to allow the doctor to either issue treatment orders over the phone, come in to see the resident, or have the resident sent to the hospital. Beyond this, the wound must be described in the medical record, including the size and depth of the wound as well as its other characteristics. This allows the care team to determine whether the wound is getting better or worse and whether the treatment being provided is effective or not. It also should have triggered either the development of a care plan for pressure ulcers or a revision in the existing one, if there was one.
Even though these are basic, well-established first steps, neither were taken when the resident first showed signs of skin breakdown. In fact neither of these steps were taken for another two weeks. When the physician was notified, he gave orders for care and for consultation with the wound care physician. However, that consultation was never obtained. When there was finally a description of the wound in the chart, it was described as being 8.2 cm x 5.5 cm with 80% covered in slough (soft, dead tissue). It was further noted that the pressure ulcer was acquired in-house.
Five days later, the resident’s chart showed that there a foul-smelling discharge coming from the wound. This is a sign of infection. A call was placed to the physician who ordered an antibiotic. Later that same day, the resident fell from her wheelchair. She had complaints of pain, so she was sent to the emergency room.
The emergency room staff recognized that the wound was in poor condition and had a surgical consult done in the emergency room. These resident was brought into surgery two days later where the surgeon described the wound as being 21 cm x 10 cm (8×4 inches) with exposure of the periosteum (the layer of nerves and blood on the outer layer of the bone).
Given the severity of the wound combined with urinary and stool incontinence, the surgeon recommended that the resident be placed on hospice. She died five days later. Cause of death was a Stage IV decubitus ulcer (pressure ulcer).
There are a number of failure in the care of this resident which led to her death:
- There was a failure to provide routine preventative care, including turning and repositioning and prompt incontinence care. If there was a care plan (and the citation in silent on that issue), these are steps which should have been included and carried out. If there was no care plan, that is a separate failure.
- Once the bed sore developed, there was a delay in excess of two weeks in notifying the physician. This resulted in the resident not receiving treatments over that period.
- The development of the bed sore should have triggered either the development of a care plan or revision of one. Clearly whatever steps were being taken was not sufficient to prevent the breakdown of this resident’s skin, so a new course of action was required.
- The consultation with the wound care physician was not obtained.
- The condition of the wound was not being tracked by the facility staff. This wound deteriorated rapidly, but there were only two time that the condition of the wound was documented – when the first set of measurements were taken and when there was foul discharge from the wound.
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.
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. 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.
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