IDPH has cited and fined Christian Nursing Home in Lincoln after a resident there developed an infected pressure ulcer from an immobilizer that was being used to treat a broken leg.
Bed sores are also known as pressure ulcers because one of the main factors that lead to the development of these wounds is pressure. Most often that pressure is caused by immobility associated with some form of debility. However, that pressure can also be produced by the use of medical devices and equipment such as braces, casts, tubing, or catheters.
When residents are at risk for developing pressure ulcers due to the use of medical devices or equipment, this must be addressed through the resident care plan. Most often, this would include the use of padding on pressure points, periodic removal of the device to check the condition of the skin, and regular assessments of the fit and positioning of the device.
The resident here was admitted as a short-term rehab patient after breaking the lower end of his femur (thigh bone) in a fall. He was placed in an immobilizer for the fracture and was supposed to be receiving care and therapy in the nursing home.
When the resident was admitted to the nursing home, he was assessed as being at risk for developing bed sores, which makes sense because he was suffering from immobility related to the fractures. A care plan was put into place which addressed the risk of the resident developing the usual kind of bed sores that you see with nursing home residents who suffer from immobility. There was no part of the care plan that specifically addressed the risk of developing pressure ulcers related to the use of the immobilizer.
The failure to care plan specifically for the development of pressure ulcers related to the use of the immobilizer was substandard care. Done properly, care planning addresses the risks of harm specific to that resident. Here, the resident faced a specific risk of harm related to the use of the immobilizer. However, that risk was never addressed in the care plan. The point of care planning is to help ensure that the risks of harm to the resident are addressed in a thought-out, systematic way and that the care needed is delivered on day-to-day, shift-to-shift basis and not left to the random decisions of nurses who may have varying levels of skill, knowledge, and work loads.
Within a week of the resident’s admission to the nursing home, there were reports made to the nursing staff by occupational therapy and physical therapy about concerns regarding the condition of the resident’s skin. The resident was finally assessed at the end of that first week as having developed deep tissue injuries to the leg where the immobilizer was applied. He alose had developed multiple bed sores on his hips and sacrum,
After the pressure ulcers developed, the care plan was revised to account for the presence of the immobilizer and the presence of the wounds. Revision of the care plan to account for the presence of the bed sores was appropriate, but at that point, the damage from poor care planning had been done. Making matters worse, the resident here also had peripheral vascular disease or poor circulation to the lower extremities which would make recovery from the wounds all the more difficult.
The resident was sent to the hospital within two weeks of admission to the nursing home suffering from sepsis related to the pressure ulcers from the immobilizer. Poor care planning all too often leads to poor outcomes and that proved to be the case here.
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Other blog posts of interest:
Moweaqua Rehab resident develops pressure ulcer from fracture brace
Sharon Health Care Elms resident develops bone deep bed sore
Christian Nursing Home resident suffers severe leg injury in fall
Flanagan Rehab resident suffers infection from bed sore
Pressure ulcer from immobilizer at Generations at McKinley Place in Decatur
Pressure ulcer from surgical boot at Amberwood Care Centre
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