IDPH has cited and fined the Loft Rehab & Nursing of Canton nursing home after a resident there developed a surgical wound infection due to the failure of the staff to obtain orders for the care of the wound.
Many persons who undergo surgery are sent to nursing homes for post-operative rehabilitation. Often part of the care is actual rehabilitation – therapy that is needed to get them “back on their feet” so that they can go home. However, a crucial part of the care that residents receive is directed toward making sure that residents receive necessary medications and lab work, that the surgical incisions are healing and free of signs of infection, and other aspects of care that are directed to making sure that nothing goes awry.
When residents are admitted to the nursing home from a hospital, there are transfer orders that go with the resident. Typically these will include things like the medications the resident is supposed to receive, treatments that the resident requires, labs that must be completed, and so forth. This assures continuity of care. When the resident is being admitted the nurse at the nursing home is supposed to review the orders with a nurse from the transferring hospital.
Additionally, when the resident is admitted to the nursing home, they undergo a number of assessments, one of which is a head-to-toe skin inspection. One of the reasons for the skin inspection is to check for the existence and condition of any bed sores or pressure ulcers. However, in the context of a post-surgical admission, this inspection is to check to see if there are signs and symptoms of infection to any of the wounds and to make sure that there are appropriate orders for care of the surgical wounds.
The resident at issue here was initially admitted to the nursing home after undergoing the removal of her parotid glands and a resection of her neck due to malignancy. However, she developed a post-surgical infection and had to be readmitted to the hospital.
When she returned to the nursing home, there were four surgical wounds present, including one which under her left breast but which was recorded in the chart as being a “chest” wound. That “chest” wound included a drain, staples, and a surgical dressing. However, there were no orders for the care of that surgical wound, and no one called the doctor or the hospital get orders for care.
As a result, the resident was in the nursing home for a week with no care being provided for the wound under her left breast. This continued until the surgical wound developed an odor, was red and inflamed, and was draining yellow and green fluid. The resident was also lethargic, said that she was not feeling good and having nausea. These are all signs of infection. The resident was brought to the hospital where the dressings were changed and the resident was placed on antibiotics. The surgeon also ordered a culture of the wound. When the cultures were completed, they showed that the wound to the breast as well as wound on her clavicle were infected with MRSA. The resident was sent back to the hospital for management of the new wound infections.
There were a number of shortcomings in the care that this resident received:
- It is unclear from the citation whether the “chest” wound recorded on the admitting assessment referred to the clavicle wound or breast wound. If the breast wound was missed all together, that is a complete failure on the skin inspection;
- There were very clearly no orders for the breast wound. When the skin inspection revealed that there was a breast wound for which there were no treatment orders, it was incumbent upon the nursing home staff to contact the doctor for treatment orders, just as physician notification is required when a resident develops a bed sore;
- After the resident was admitted, there were multiple shifts where no one seemed to recognize that there were no orders for the treatment of the breast wound. Multiple opportunities missed.
- Typically, the condition of a post-operative wound is recorded on a per shift basis. This is because a surgical wound infection is a serious matter which needs to be addressed promptly. The condition of the dressing when the nurses first noted the odor was described as being filthy, which means that there had likely been multiple shifts where either no one paid any attention to the breast wound or to the fact the dressing had not been changed.
In short, there were several levels of failure at the nursing home in the care of this resident, all of which led to a serious infection of the surgical wound. The resident had been admitted to the hospital for care for this, but this will likely require extensive use of antibiotics and likely surgical excision of the infected tissues. This is a situation which was made worse, not better by the care that this resident received.
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