IDPH has cited and fined Flanagan Rehabilitation and Health Care Center nursing home after a resident there suffered an infected bed sore which required surgery.
Bed sores are a major focus of patient care in nursing homes. There are specific federal regulations regarding bed sores and they are a specific area of focus in the care planning process.
The Braden scale is the most common tool used to assess a resident’s risk of developing bed sores. The resident was who the subject of this citation was assessed as being at high risk for skin breakdown when her Braden score was completed. When a resident is at risk or high risk for developing bed sores, then the usual next step is to put a specific care plan into place to address that risk. However, despite the fact that she was assessed as being at high risk, no care plan to prevent bed sores was put into place.
The nursing home’s policies and procedures called for daily skin inspections when a resident was at high risk for skin breakdowns. However, during the two month period between when the resident was assessed and when she was finally sent to the hospital, only weekly skin checks are documented.
A few weeks after the initial assessment was done, the resident developed a skin breakdown over the sacrum. The CNA who found it reported it to the nurse who notified the doctor and received orders for treatment. Medihoney was applied to the wound and it was dressed, but there was no further documentation of the condition of the wound or of any further treatment being provided during the next month up until the resident was sent to the hospital.
The only other time there was any record of the condition of the resident’s wound was when a CNA noted the presence of a wound on a shower sheet. The nurse on duty signed off on the shower sheet, but there was no documentation of the condition of the wound or of further physician notification.
Three and a half weeks later, the nurse found the resident unresponsive. The physician was notified and the resident was sent to the hospital. There, they found that she was suffering from a urinary tract infection and there was an abscess on the buttocks which was infected with MRSA. She was diagnosed as suffering from metabolic encephalopathy due to sepsis. The resident was brought to surgery where the wound was debrided and the abscess drained. The surgeon described the extensive infection that was present and said that it would have been present for several days causing the resident significant pain.
There are a number of failures in the care that this resident received. First, despite the fact that she was assessed as being at high risk for developing bed sores, no care plan to address that risk was put into place. Second, the facility’s own policies and procedures were not followed in that the daily skin checks were not done. Third, there was no further care provided to the bed sore once it was discovered other than the initial treatment and dressing. Getting bed sores to heal is a lengthy process. Fourth, there was no follow up to the wound that observed and documented in the shower sheet. Finally, the declining condition of the wound as shown in the emergency room was not ever discovered by the staff. Besides the skin checks that were supposed to be done daily per facility policy, the skin checks that were done during showers, the staff would have been providing incontinence care to this resident which would have offered additional opportunities to discover the decline in the condition of the resident’s skin and notify the doctor. In short, there was a long list of failures in the care that this resident received, resulting in a serious, infected wound which required surgery.
These kinds of failures reflect poorly on the training levels of the staff and are indications that management is unwilling to invest in training the staff. 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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