The Illinois Department of Health has cited and fined Mattoon Rehab & Health Care Center when, according to state investigators and facility records, a resident’s leg wound dressings went unchanged for more than two weeks, and her wounds deteriorated significantly with copious drainage and odor. The resident was hospitalized for cellulitis in both legs, a complicated wound infection, and a multidrug-resistant bacterial infection requiring intravenous antibiotics.
The resident was a cognitively intact woman with chronic lymphedema and multiple open wounds on both legs. Her wound clinic nurse practitioner had ordered daily wound care, including cleansing the wounds with normal saline, applying an antimicrobial dressing, wrapping with gauze, and applying compression. However, when these orders were entered into the facility’s system, they were entered as three-times-weekly treatments to coincide with the resident’s lymphedema therapy sessions on Mondays, Wednesdays, and Fridays. There is no documentation that this change in frequency was ever clarified with the wound clinic. Critically, even those three-times-weekly orders were never transcribed onto the facility’s treatment administration records for November or December.
A physical therapy assistant was the staff member actually performing the wound dressing changes during lymphedema therapy sessions. When the resident’s lymphedema therapy ended because her wounds had deteriorated and were draining copious green drainage, the physical therapy assistant stopped providing the wound care. According to investigators, there was no documentation that nursing staff assumed responsibility for the wound care after the physical therapy assistant stopped providing treatment. The physical therapy assistant told investigators she had not received formal wound care competency training from the facility, that the resident was not on the required Enhanced Barrier Precautions or Transmission Based Precautions during her wound treatments, and that she did not wear a gown during wound care.
When the resident was next seen at the wound clinic, the wound clinic nurse practitioner found her dressings dated from more than two weeks earlier. The wounds had deteriorated dramatically. The wound clinic nurse practitioner later told investigators: “The wounds had deteriorated, had an odor and had an abundant amount of green drainage. The resident was crying due to the pain and infection, and required hospitalization to treat the infection.” The resident was sent to the emergency room directly from the wound clinic. Hospital records noted purulent drainage weeping through her dressings and foul odor. She was diagnosed with cellulitis in both legs, a complicated polymicrobial wound infection, and an infection with a multidrug-resistant organism known as Acinetobacter baumannii. She required intravenous antibiotics during her hospital stay.
When investigators looked deeper, additional concerns emerged. A subsequent wound clinic appointment was cancelled by the facility due to transportation issues — yet the facility’s transportation aide stated he was unaware of the appointment until he saw a note when he came to work the next day, and said he would have taken the resident if he had known. The resident herself told investigators in her own words: “I have leg wounds that should be wrapped daily, but once in a while the nurses forget to change the dressings. I had infection in my legs and went to the hospital.” The facility’s wound nurse confirmed there were no documented wound assessments during the period of concern. The Director of Nursing acknowledged the wound treatments were not completed, that the orders should have been transcribed onto the treatment administration record, and that nurses should have taken over the wound care once the physical therapy assistant stopped.
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.
