IDPH has cited and fined Avantara of Elgin nursing home after a resident there developed an unstageable buttocks wound due to the failure of the nursing home to develop a pressure ulcer prevention care plan.
Bed sores or pressure ulcers are a major issue in the nursing home industry. They have a significant impact on the long-term health and well-being of nursing home residents. The federal government thinks that these are important enough that they are part of the nursing home’s Medicare star ratings.
One of the first thing that happens when a resident enters a nursing home is that they get a full body inspection to determine whether there are any skin breakdowns. Bed sores are rated on a scale of 1 through 4, with 4 being the worst (involving exposed muscle or bone). Some wounds are considered unstageable which means that they are at least a Stage 3 bed sore (into the subcutaneous tissue), but could be a Stage 4 bed sore, but the wound bed is obscured by dead tissue. Federal regulations provide that when a resident develops a bed sore, they must receive care treatment and services to promote healing, prevent infection, and prevent the development of new wounds. The presence of a bed sores, whether obtained before or after the resident enters the nursing home, is something that requires physician notification so that orders for treatment can be obtained.
When a resident comes into the nursing home with no bed sores, federal regulations provide that the nursing home must provide care consistent with professional standards to ensure that the resident doesn’t develop pressure sores unless they are unavoidable. To comply with the regulation, the nursing home must do an assessment of the resident’s risk of developing bed sores, usually using a tool such as the Braden Scale. If the resident is at risk for developing pressure sores, well -run nursing homes will put a pressure ulcer prevention care plan in place to prevent the resident from developing these kinds of wounds. Typically, this includes frequent skin checks, use of pressure relieving devices, prompt incontinent care, and frequent repositioning.
The resident at issue was admitted with intact skin, meaning that he should not have developed bed sores unless they were unavoidable despite being providing with care consistent with professional standards. That would involve developing a pressure sore prevention care plan which would include interventions or steps to be taken to keep him from developing bed sores. However, one of the nurses told the state surveyor that they did not put interventions in place unless the resident came in with bed sores already present.
Sadly, the course of care for this resident seems to bear that out. There was no pressure relieving devices such as a specialized mattress or wheechair cushion put in place until after the resident developed an unstageable pressure ulcer. The resident further described being left unattended for a period of 6-8 hours and being placed in an incntinent brief when the staff did not think that they would be able to get him to the bathroom. There was no regular program of repositioning the resident which led to him being left in his wheelchair for hours on end.
There are basic measures that are put into place for almost every resident that is at risk for developing pressure ulcers, including the ones outlined above. It seems that none of these were put into place for this resident, and that seems to be the norm at this nursing home is you believe the statement made to the state surveyor. It is a little like designing a car with no brakes and then adding them only after the car crashes. It represents a horrible systemic failure that poses a risk of harm to each and every resident at this nursing home.
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