IDPH has cited and fined Manor Court of Clinton nursing home after a resident developed heel and hip pressure ulcers.
The resident was admitted to the nursing home for a short-term rehab stay. This means that whatever long-term chronic conditions he suffered from, there was an expectation that he would return home and whatever long-term medical problems he had would not keep him in the nursing home indefinitely.
On admission, the nursing staff did the usual head-to-toe body assessment and found that he did not have any pressure ulcers. This meant that according to federal regulations, he was entitled to receive care and services to prevent pressure ulcers (or bed sores) and that he should not develop them unless they were unavoidable. This was not some pipe dream for this man because of part of the care planning process, his risk of developing bed sores was measured using the Braden Scale and he was determined to be not at risk.
However, within 3 weeks, he developed a bed sore on his left heel. It was a Stage 2 pressure ulcer. Once the bed sore developed, federal regulations required that he be provided care, treatment and services to promote healing, prevent infection, and prevent the development of new pressure ulcers. Over the next several weeks, the wound continued to decline and he developed a second wound on his right hip. The resident’s son asked that he be referred to a wound clinic to be treated by a specialist.
During an early visit to the wound clinic, there was an order entered that he be provided with a low air-loss mattress. This is a pressure-relieving device which is intended to be used to prevent bed sores from developing and to help existing wounds heal. The low air loss mattress was not obtained until after he returned from the hospitalization that followed further decline of the wounds.
As the weeks passed, the records showed that the wound showed further signs of decline in terms of the size of the wound, the appearance of the wound, and the development of an odor. The presence of an odor is often a sign the bed sore has become infected with cellulitis. Beyond the signs of infection, the wound was become ever more painful for the resident.
Shortly before the resident was sent to the hospital, one of the nurses went to do a dressing change on the heel wound and found that the dressing was loosely intact and that there were maggots on the dressing and in the wound.
As both wounds continued to decline, the resident’s doctor ordered him transferred to a hospital where he underwent a surgical debridement of the wounds and treatment for sepsis from the infections of the wounds.
Capping all of this off, after the resident returned to the nursing home from the hospital, the state surveyors were in the facility and they saw that the resident was not being repositioned, that the low air loss mattress was not being used properly, and that orders for care were not being carried out.
This is a resident who was admitted to the nursing home with an expectation of a short term rehab stay and was not considered at risk for developing bed sores. The heel wound developed shortly after admission and continued to decline. Before the situation spiraled out of control leading to the hospital admission, there is clear evidence that physician’s orders were not being followed. Once he returned there was additional evidence that this was continuing to happen and even the routine care which is required to prevent bed sores and promote healing was not being done. All of this speaks to chronic problems with the delivery of care at this facility.
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Other blog posts of interest:
Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur
Unstageable bed sore at Nokomis Rehab
Staff at Hilltop Skilled Nursing fails to follow physician orders, Stage 4 bed sore results
Residents injured in falls at Manor Court
Manor Court resident breaks neck in fall
Four residents develop bed sores at Morton Villa
Resident suffers injury from being left on bed pan at Accolade Paxton Senior Living
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