IDPH has cited and fined Rushville Nursing & Rehabilitation Center nursing home after a resident there suffered significant complications from an untreated surgical wound infection.
One of the common reasons that people are admitted to nursing homes is for rehabilitation after a hospitalization. This may include post-surgical care. One of the basic functions of the nursing staff in caring for residents who are admitted for post-surgical care is to monitor for signs and symptoms of infection. Signs and symptoms of infection may include abnormal white blood cell counts; foul-smelling purulent drainage (pus); fever; redness and warmth around the surgical site; the presence of slough and necrotic tissue; confusion; increased respiratory rate and pulse; and low blood pressure.
Nurses do not need to know how to treat an infection – that is for the doctors to determine. However, because doctors are not present in an nursing home 24/7, the nursing staff is the “eyes and ears” of the doctors and must notify the doctor when signs and symptoms of infection are present. The doctor then can decide to come to the nursing home himself to treat the patient, issue orders over the phone, or order the resident sent to the hospital to receive care there.
The resident involved was admitted to the nursing home after undergoing a complicated abdominal surgery which resulted in multiple surgical wounds, the placement of abdominal mesh, a surgical drain, and the need for the use of a wound vac. However, there was no evidence of a wound infection at the time the resident was admitted to the nursing home, and the day before the resident was transferred, her lab work showed that there was a normal white blood cell count. The orders were for dressing changes every Monday, Wednesday, and Friday and to return to the wound care clinic two weeks later.
The first 10 days after the resident was admitted to the facility were relatively unremarkable. However, two days before she was to go to the wound clinic, the floor nurse noted a very foul odor to the would. She notified the wound care nurse, who was scheduled to see the resident and do a dressing change that day. The wound care nurse noted tunneling in the surgical wound, purulent drainage, a foul odor, reddened skin on the edges of the wound, moderate slough and necrotic tissue. These were obvious signs of infection. She faxed a note to the doctor’s office asking for an order to give an antibiotic. In response, the physician’s nurse practitioner called and asked the floor nurse to check for warmth around the edges of the wound. The floor nurse reported back that there was no warmth present, so the nurse practitioner decided to assess the wound herself the following day.
When the nurse practitioner arrived the following day, the wound vac and dressing were in place. She chose to not take down the wound vac and the dressing to assess the wound itself. Seeing no signs of infection on the exterior and with the resident not running a fever, she decided to let the wound clinic address things when the resident went in for her appointment the following day.
The next day, the resident had her scheduled appointment with the wound care clinic. However, when the transportation aide arrived in the resident’s room to take her to her appointment, she discovered that the resident was not dressed and could not be make the scheduled time at the wound clinic. The staff told the aide that they did not get the resident dressed because they were unaware of the appointment at the wound clinic. The clinic advised that they could not get her in later that day, so the appointment was rescheduled for five days later. Later that same day, lab work for the resident showed an elevated white blood cell count.
Three days later the notes in the resident’s chart show that there was a foul odor and slough in the wound bed with edges of the wound being reddened. However, there was no notification of the doctor of this. The following morning, there as foul smelling drainage coming from the drain, but the doctor was not notified. That evening, there was additional foul-smelling drainage from the drain, so the nurse on duty faxed a note to the doctor’s office after hours.
The next day was the rescheduled appointment at the wound clinic. That morning the staff at the nursing home noted that the drain was producing thick, brown drainage. The nurse practitioner was in and noted that the fax the day before had been received after hours and that the resident was scheduled to go to the wound clinic later that day.
On arrival, the staff at the wound clinic noted that the resident did not look well. They took her blood pressure and found that it was low. Inspection of the wound revealed that the abdominal wall had separated and that there was fecal matter in the wound and draining into the drain. They concluded that the wound was badly infected and had the resident transferred to the hospital. The nurse practitioner at the wound clinic later told that the state surveyor that the wound had not been cared for appropriately at the nursing home and that the wound did not deteriorate to that extent overnight. She also said that the nurse practitioner at the nursing home told her that the staff at the nursing home did not tell her of the extent of the deterioration of the wound and that she had only looked that he exterior of the wound with the wound vac and dressings still in place.
At the hospital, lab work showed that the resident’s white blood cell had increased further. She was diagnosed as suffering from low blood pressure, a necrotic wound of the abdominal wall with surgical site dehiscence, fecal matter draining into the surgical wound, and an intrabdominal infection.
As a general proposition, early intervention with an infection yields better outcomes. There were a number of times when earlier intervention would have been appropriate, but the infection went unchecked for a week after the first signs of infection were present. This allowed the infection to spread and worsen. This resident will likely have to undergo multiple surgeries to try to resolve this infection and undergo a lengthy course of antibiotics. Once the infection is clear, there will likely be extensive surgical wounds which will be difficult to close, leaving this resident at risk for further infections and complications.
There are a number of places where earlier action should have been taken which would have led to an improved outcome for this resident:
- When the floor nurse first recognized that there was a foul odor to the wound, this was a sign of infection. This in itself required physician notification, not just referral to the wound care nurse. The wound care appropriately asked for an order for antibiotics. The nurse practitioner should have likely given the order. However, the content of what was communicated to the nurse practitioner is important because it was apparently not enough to justify a phone order for the necessary antibiotics. Nurses need to communicate enough information to provide a basis for medical decision-making.
- When the nurse practitioner came in the following day, she assessed the wound without taking down the wound vac and the dressing, making it impossible to see what was actually underneath. This deprived her of vital information for her decision-making. The supervising physician for the nurse practitioner reportedly told the administrator that he did not condone the practice of trying to assess the wound without removing the wound vac and dressing.
- On the day of the scheduled appointment, the resident was not dressed and ready to go resulting in the cancellation and rescheduling of the appointment. The resident was not ready to go because the staff was reportedly not aware that she had an appointment. Getting residents to scheduled doctor appointments is a basic function in providing care in this setting. There was a clear breakdown in that process.
- Once it became apparent that the resident was not going to make the appointment as scheduled, the urgency of the resident being seen was not communicated to the wound care clinic. The staff already had concerns about the resident having an infection and part of the thought process for the nurse practitioner the day before had been that there was a pending wound care clinic appointment. When that was not going to happen, the clinic needed to know that there was some urgency for them to see the resident, and why.
- During the days leading up to the rescheduled wound clinic appointment, the resident doubtless continued to show signs and symptoms of infection, most of which were not noted by the staff. The few times that there notes suggestive of the presence of infection, there was no notification to the doctor until the after-hours fax was sent the evening before the rescheduled appointment. When a resident is demonstrating the kind of advanced signs of infection that this resident was showing, simply faxing a note over was not sufficient – a call or page was required. Why? Because we know that no one responded to the fax sent the evening before – resulting in additional delay and spread of the infection.
There were multiple missed opportunities to drive a better outcome for this resident, spread across several days and several health care providers, including the nurse practitioner. The net result is that this resident will experience significant, needless suffering and complications.
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