IDPH has cited and fined Oak Brook Care Center nursing home after resident there developed a Stage 4 bed sore from an immobilizer.
“Bed sores” are also known as “pressure ulcers” because one of the main factors that cause these wounds is pressure. Most often the pressure that causes them is pressure brought about by immobility which is why you normally see bed sores develop on the bony prominences such as the hips, buttocks, sacrum, or heels. However, immobility-related pressure is not the only type of pressure which can cause skin breakdown as pressure from medical devices and equipment such as braces, immobilizers, catheters, casts, bed pans, and other devices and equipment can cause bed sores or pressure ulcers to develop as well.
Because the risks of developing pressure ulcers from medical devices and equipment is well-recognized, interventions such as regular skin checks should be included as part of the care-planning process and should be incorporated into the nursing home’s policies and procedures. When early signs of a skin breakdown are identified, physician notification is required so that the physician can determine whether there are suitable alternatives to the device that is causing the pressure, whether the use of the device is necessary, or whether there are ways in which the use of the device can be modified so as to eliminate or reduce the pressure caused by the device. It also allows the physician to enter orders for treatment.
The resident at issue was admitted to the nursing home with an immobilizer in place for treatment of a fractured kneecap. At the time that the resident was admitted to the nursing home, there were no bed sores present, according to her Minimum Data Set (MDS). Federal regulations provide that when a resident is admitted to a nursing home with no pressure ulcers present, they must receive care consistent with standards or professional practice such that the resident does not develop pressure ulcers unless they were unavoidable.
Within two weeks of her admission to the nursing home, the resident developed some redness to the calf, likely caused by some rubbing by the brace. The nursing staff noticed the wound and referrals for treatment by a wound care nurse and a wound care physician were obtained. However, the family was not notified and the treating orthopaedic surgeon was not notified for over a week.
When the treating orthopaedic surgeon was notified of the presence of the wound, he gave instructions that the immobilizer could be removed when the resident was in bed but that it needed to be left on during transfers and while the resident was in her wheelchair. Limiting the time that the resident was in the immobilizer would have helped with healing the wound on the calf by reducing the exposure of skin to the pressure from the use of the immobilizer. However, compliance with this order was not tracked in any meaningful way.
By the time that the wound care physician saw the resident for the first time over a week after when the wound was first seen, the wound was characterized as a full thickness wound and was much larger in size. It also had slough and necrotic tissue, indicating that there was dead tissue from the wound. This represented a significant decline in the condition of the wound from when the wound was detected. There was no notification to the family of the decline in the wound.
The wound care physician issued orders for the treatment of the wound. However, there were multiple days when those treatment orders were not carried out. The wound continued to decline and worsened to a Stage IV pressure ulcer with exposed tendon. Additionally, the facility failed to keep multiple telehealth appointments with the treating orthopaedic surgeon who was also unaware of the continued decline in the condition of the wound.
Approximately 8 weeks after the wound on the calf was first detected, the resident was transferred to the hospital for a urinary tract infection. The hospital recognized that the wound had a cellulitis infection and began to treat it with a bedside debridement and use of a wound vac. The care of the wound was being managed by a plastic surgeon. The treating orthopaedic surgeon told the state surveyor that the nursing home did not advise him of the decline in the condition of the wounds and that the wound would not have declined to the point that it did had his instructions to remove the brace been followed.
For their part, the administrator and Director of Nursing blamed agency staff for failing to complete ordered wound treatments and stated that it had been an ongoing issue with agency staff. Of course, the nursing home remains responsible for the provision of care and the administration of the nursing home is responsible for the operation of the nursing home. The failure to hire or retain qualified staff or get agency staff in who will get the job done will inevitably have consequences for the health and well-being of the residents. 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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