IDPH has cited and fined the Grove of Berwyn nursing home after the staff there failed to treat a resident who developed a pressure ulcer.
The resident at issue was admitted to the nursing home on March 21 without any bed sores present. The resident was sent back to the hospital and was readmitted on April 5 with a Stage 3 pressure ulcer on her buttocks. There was a physician order sheet which included orders for treatment of the bed sore. However, those orders were never transcribed onto the resident’s Treatment Administration Record on the resident’s chart and there was no care for the wound provided through April 24. On April 24, the facility’s wound doctor arrived at the nursing home and performed a sharp debridement of the the now unstageable bed sore and issued additional orders.
One of the basic items that must happen any time a resident is admitted or readmitted to a nursing home is that the orders for treatment be entered into the resident chart and then carried out. This resident apparently developed a bed sore while at the hospital and returned to the nursing home with orders for their treatment. The failure to include these orders in this resident’s chart led directly to the resident not receiving the treatment ordered.
Past that, when a resident is admitted or re-admitted to a nursing home, that should re-start the care planning process. The care planning process includes a full assessment of the resident including a full body check which should have revealed the presence of the bed sore and notfication of the doctor for treatment orders. The facility also had a policy in place calling for weekly skin checks which were apparently never done.
Federal regulations require nursing homes to provide care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new bed sores when a resident is admitted to the nursing home with a bed sore. Here, there were at least three breakdowns in the delivery of care: the failure to transcribe the orders from the hospital, the failure to do the full body check which is part of the care planning process, and the failure to do the weekly skin inspections. Each of these failures resulted in this resident going nearly three weeks without care and in the decline of the bed sore which led to the debridement of the wound.
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