IDPH has cited and fined Franciscan Village nursing home in Lemont after a pressure ulcer on a resident’s foot decline due to a lack of treatment, resulting the resident developing osteomyelitis.
Federal regulations regarding bed sores provide that after a resident develops a pressure ulcer or bed sore, they are to receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new pressure ulcers.
The development or worsening of a bed sores is an issue which requires physician notification so that the doctor can issue orders for treatment. It also requires revision of the care plan for treatment and prevention of bed sores. While the doctor is the one who issues the orders, in many nursing homes, the doctor defers almost entirely to the judgment of people who have been specially trained in the care and treatment of bed sores such as wound care nurses or wound care doctors.
The resident here had been under the care of a wound care doctor for a bed sore on his foot from the time of the start of this admission up until the point where his Medicare days had been exhausted, at which point, care of the bed sore was transitioned over to the primary care doctor who in turn apparently allowed the wound care nurse to manage the care of the wound. When questioned by the state surveyor, the wound care nurse confirmed that this was the case and in any event, multiple progress notes from the primary care doctor had no notation of the condition of the wound.
Approximately a month after the wound care doctor stopped seeing the resident, the wound declined and an order for daily dressing changes and the use of a chemical debriding agent was obtained. These orders were left in place for two months, at which time, the orders for the dressing changes and the use of the chemical debriding agent were no longer part of the monthly physician order sheets. These orders were missing from the Treatment Administration Records for two months until they reappeared about a week before the resident went to the hospital. The resident chart indicates that the care had stopped.
The bottom line: this resident went almost two whole months without there being any record of the daily dressing changes being done and without the chemical debriding agent being done.
This changed when another nurse noted there being a malodor to the foot and there being serosanguinous drainage from the wound on the foot. These are all signs the wound had become infected. The resident was sent to the hospital 10 days later where he was diagnosed with chronic osteomyelitis of the foot.
There are a number of failures which contributed to the poor outcome for this resident. The most obvious is the cessation of treatment for the wound when the wound had not yet healed, the physician had not ordered treatment stopped, and the resident was still in need of care. The reason for this was not made clear in the citation, but in context, it appears to be due to a clerical error in continuing orders in form month to month in the resident chart.
However, that is far from the end of the strong of failures. The attending doctor was carrying a resident with a diagnosis of having a pressure ulcer to the foot but did nothing to actually monitor the course of care. One of the protocols that is followed in the nursing home industry when a resident is suffering from a pressure ulcer is that there are regular (usually daily) checks done of the condition of the skin, and either none of these were being done or no one was reporting or documenting the decline of the wound until it was badly infected enough that drainage and malodor were present.
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