The Illinois Department of Health has cited and fined Landmark of Oak Lawn Rehab and Nursing Center when, according to state investigators and facility records, a resident admitted to the facility with no documented wounds later developed a severe pressure wound on her sacrum and was hospitalized weeks later with sepsis, an unstageable decubitus ulcer, and necrotizing fasciitis, a serious soft tissue infection. Hospital imaging found soft tissue gas extending into her buttock and gluteus muscle, and emergency surgery was required to debride the wound, which by then measured 15 by 15 by 4 centimeters.
The resident was admitted to the facility with diagnoses including Parkinson’s disease, muscle weakness, mild protein malnutrition, and other conditions, but the facility’s own admission assessment documented she had no wounds and intact skin. Records from her previous facility documented that she was at moderate risk for skin breakdown at the time of transfer. However, the facility’s admission Braden assessment classified her as low risk. The Assistant Director of Nursing who completed the assessment was unable to explain how the risk level had changed from moderate to low given the resident’s history of skin breakdown, and later acknowledged that the assessment did not accurately reflect the resident’s actual risk factors. The citation also noted that the resident had multiple medical conditions associated with elevated pressure ulcer risk, including immobility, incontinence, Parkinson’s disease, and nutritional concerns.
Several weeks after admission, according to the citation, an open area on the resident’s sacrum was identified. The wound care physician was notified and orders were given for a specific wound treatment regimen. According to the order audit, the wound care orders were not entered into the system until two days after they were given. A progress note documenting the open area was entered as a late entry. By the time the resident was sent to the hospital several days later, she was presenting with altered mental status, fever, and a large unstageable sacral decubitus ulcer with purulent drainage. She was admitted to the hospital with severe sepsis, broad-spectrum antibiotics were initiated, and a CT scan raised concerns for necrotizing fasciitis. General surgery was consulted and the resident was emergently taken to the operating room for extensive debridement of the wound.
When the wound care physician was interviewed by investigators, he expressed significant concerns about the facility’s wound care infrastructure. He noted that during one of his visits, the resident was found with feces and urine in the wound bed. He stated the facility has not had a dedicated wound care nurse and the nurse rounding with him was “not a wound care nurse/wound care professional” and could not communicate with him effectively about wound conditions, measurements, drainage, or signs of infection. He stated that if he had been made aware that the resident’s wound was changing and she was experiencing signs and symptoms of infection, he could have ordered antibiotics. He stated specifically that he had communicated to the Director of Nursing that the facility needs a wound care nurse, and asked if the surveyors could make the facility aware of the same.
Investigators’ observations during the survey documented a similarly concerning picture. During a skin assessment, the resident’s wound dressing was found heavily soiled with urine. Her adult brief was heavily soiled with urine. She was resting on multiple layers of linen, all soiled with urine and stained. She had a urinary catheter in place and was resting directly on the catheter tube and ports. The wound itself was very large, extending from the sacrum to both buttocks. A nurse performing the wound treatment was observed handling clean linens with the same gloves she had used to clean a brown substance from the resident’s perineal area, and did not clean the resident’s skin surrounding the wound before applying the clean brief and treatment dressings. During a continuous observation lasting more than two hours, the resident was not repositioned to relieve pressure from her sacral wound — when staff finally entered the room, they slid her up in bed using the pull sheet but left her in the same supine position.
The Director of Nursing acknowledged the wound was facility-acquired and that the facility did not have a wound care nurse or a designated nurse to manage wounds between the physician’s weekly visits. She agreed with the wound physician that the facility needed one. The Assistant Director of Nursing stated she does not measure or stage wounds. A licensed practical nurse responsible for wound “evaluations” stated she was not actually evaluating wounds — she was transcribing information she received from the wound doctor or facility via email onto another document, sometimes working remotely. The facility’s weekly wound evaluation for this resident was created nearly two weeks after the open area was first identified.
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. Our experienced Illinois 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.
