In a tragic case, the IDPH has issued a citation to Bridge Care Suites in Springfield, IL, after one of its residents died from an infected bedsore.
What was supposed to be a short stay turned into an agonizing and ultimately fatal battle for the resident.
From Post-Injury Rehab to Fatal Infection
The resident had broken her hip in a fall and was admitted into Bridge Care for short-term rehabilitation. At the time of her admission, she already had a small bedsore on her tailbone, about 3×4 centimeters.
When a resident comes to a nursing home with a bedsore, the standard practice is for the facility’s staff to contact the doctor for treatment orders. This was not done, because staff were instructed to only call the doctor if the bedsore was Stage 3 or higher. The fact that they didn’t reach out to a doctor upon the resident’s admission indicates that her bedsore was only Stage 1 or 2.
Within 19 days of her stay, the resident’s bedsore grew to the stage 3 category. At this point, her care plan only included the use of a pressure-relieving cushion on her wheelchair and no other intervention for bedsore. Her wound had worsened, but nobody obtained additional treatment orders from the doctor.
The resident then visited a wound care clinic. There, a nurse practitioner saw that the resident’s wound was not properly dressed and that she was not on a pressure-relieving wheelchair cushion.
In the NP’s account to the state surveyor, she was mortified by the resident’s condition, particularly to the “nasty” wound that already had a foul smell. It had also grown in size, had dead tissue on the wound bed, and was tunneling underneath such that bone was palpable. The NP debrided the wound, which was now classified as a Stage 4 bedsore.
Unfortunately, the nursing home still did not update the resident’s care plan despite the progression of the wound. Within four days of her return to the home, she began to suffer significant pain at her coccyx (tailbone), a common sign of osteomyelitis or bone infection.
Again, despite the new complaints, there was no call made to the doctor. The resident’s pain increased, and she now also had nausea and changes in mental status.
Meanwhile, her son had grown concerned and called the nursing home. He had to wait for a callback from the nurse’s station, at which point they asked him what he wanted to do.
Paramedics arrived at the nursing home and transported the resident to the ER. On arrival, she was already struggling to breathe and had no pulse or blood pressure. She was pronounced deceased within an hour. The pathologist certified her cause of death as sepsis and decubitus ulcer, and also found neglect in the case.
Multiple Failures in Resident’s Care
There were multiple failures in caring for this resident, which started at the moment of her admission when the staff did not notify the doctor about the bedsores. Her care plan was thus inadequate.
Second, her care plan was not revised as her wound worsened. Updating the care plan is a fundamental step in the care planning process. Nursing homes have the responsibility to look out for progressing medical issues in any of their residents and to reach out to a physician so that the resident’s care plan can be revised accordingly.
Bedsores are a particularly crucial issue because they are so common and can easily lead to serious medical conditions. The US has specific federal regulations mandating nursing homes to provide care to prevent sore infection, promote its healing, and prevent additional bedsores.
The deceased resident’s bedsore should have been taken seriously.
Further, her additional complaints of increasing pain should have prompted immediate medical action. Yet the physician was not called even at this point.
In an interview with the state surveyor, the wound care nurse at the facility said that when he began there, they did not have a wound care nurse in place. As he took on the role, he only got minimal training and almost no supervision. He did not even know of any policy or procedure to guide him in the provision of care.
These comments indicate serious shortcomings in facility management, involving poorly trained, unqualified, or inadequate staff.
This substandard condition sadly led to the demise of an individual — a very preventable death. A nursing home can take steps to prevent or heal bedsores and thus protect their residents from life-threatening infections — if only the facility is serious and competent in fulfilling their duties.
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