IDPH has cited and fined Eden Village Care Center nursing home in Glen Carbon after a resident there developed bed sores on both heels.
Federal regulations provide that when a resident is admitted to a nursing home without bed sores that they receive care consistent with professional standards of practice to prevent bed sores and that they do not develop bed sores unless the resident’s clinical condition demonstrates that they were unavoidable. Once a resident develops a bed sore, federal regulations require that the resident receive treatment and services necessary to promote healing, prevent infection, and to prevent new sores from developing.
Bed sores occur most often on the bony prominences. One of those areas is the heels. This is because the weight of the body and the creates a “pinch point” between the bony prominence and the resting surface (usually a bed or chair) where the small blood vessels that supply oxygen and nutrients to the skin can be compressed. This is why immobility is a major risk for the development of bed sores and a huge impediment to their healing. The regular means of combating immobility is pressure relief which consists of turning and repositioning the resident and floating the heels off the bed.
The resident at issue was admitted without any skin breakdowns but assessed (likely using the Braden scale) as being at risk for skin breakdowns. The resident had a pressure ulcer prevention care plan put into pace which included daily skin checks, turning and repositioning every two hours, and floating the heels while in bed. The resident developed a pressure wound on her left heel approximately three and a half weeks after being admitted to the nursing home. The flow sheets indicated that the daily skin checks were not done on just under half of the days before the wound on the left heel developed. At that point, the doctor entered an order for the heels to be floated, among other orders for treatment.
Approximately six weeks after the wound of the left heel developed, an unstageable pressure ulcer was discovered on the right heel. When the surveyor reviewed the resident chart, she discovered that there were multiple days where the floating of the heels did not occur. The nurse practitioner interviewed by the suveyor (likely the wound care nurse) stated that the bed sores to the heels were likely avoidable had the heels been floated as called for in the resident care plan and the treatment orders.
Unlike incidents such as nursing home falls or choking accidents in nursing homes, the development of bed sores does not usually occur in a flash moment of time. In other words, the development of bed sores is most often the product of days if not weeks of the resident failing to receive the kinds of routine care (such as repositioning and floating the heels) which is necessary to prevent the development of bed sores and to promote the healing of existing wounds. When that routine care is not done, this is the kind of outcome that you have.
The question of course is why is this routine care not being done? Frequently it relates to understaffing of the nursing home, which is an issue which I would certainly examine in a nursing home abuse and neglect lawsuit. Understaffing of is one of the key features of the nursing home business model. 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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