IDPH has cited and fined Moweaqua Rehabilitation & Healthcare Center nursing home after a resident there developed a pressure ulcer from a fracture brace.
The resident at issue was admitted to the nursing home after suffering a fracture to her femur. The resident was sent to the nursing home with a brace which was intended to immobilize the fracture.
One of the times that is fraught with risk for a nursing home resident is when a resident is admitted to a nursing home from the hospital. Typically, there are specific orders sent with or in advance of the resident’s arrival at the facility for the resident’s general medical needs as well as the specific medical issues that had the resident in the hospital to begin with. The reason that this is a time of high risk for the resident is that orders may be omitted or mis-transcribed. This can lead to things like nursing home medication errors or needed care not being delivered.
When the resident arrived in the nursing home, there were no orders in place with regard to the fracture brace – where it should be positioned, how long it should be on, how it should be padded, how skin checks should be performed. Bed sores are also known as “pressure ulcers” or “pressure sores” because one of the main causative factors is pressure from the skin. With bed sores, that is usually pressure put on the skin by the weight of the body against the resting surface (usually a bed or chair). When a resident is wearing a brace, cast, or other medical appliance, the pressure is between the skin and the medical device. With things like a splint, brace, or cast which is being used to treat a fracture, this is especially true because the device is intended to be on tight enough to immobilize the fracture site.
Two days after the resident was admitted to the nursing home, an aide saw that the brace was on the resident’s lower leg and that there was blood. She brought in the nurse who removed the brace and saw that there was an indentation from pressure from the brace. There was a wound just above the ankle and measured 10.5 cm x 4 cm with drainage and a foul odor. This wound was caused by misapplication of the brace. Eventually the wound declined to the point that there was exposed muscle and ligaments.
Due to the her immobility, the resident was also supposed to have been placed on a turning and repositioning schedule, but was not. As a result, she also developed bed sores to her heel and sacral area.
The proper course of action when this resident was admitted to the facility would have been to call the doctor to obtain orders for care. The resident was admitted with a readily obvious medical device in place. This should have prompted the nurses to ask, “What do we need to do to take care of this?” This simple question was not asked, and as a result, necessary care – proper placement of the brace, proper padding and pressure relief, inspection of the skin – was not done with disastrous results.
When nursing home staff does not have time to think to ask basic questions needed for proper care of the residents, that is a sign of an understaffed nursing home. 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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