IDPH has cited Sharon Health Care Elms nursing home in Peoria after a resident there developed a Stage 4 bed sore on her ankle due to the failure of the staff to apply protective boots as called for in the resident care plan.
There are a number of factors which predispose nursing home residents to developing bed sores, also known as pressure ulcers. Chief among these is immobility. Lack of movement over a prolonged period of time creates pressure on the small blood vessels which supply the skin. This pressure is produced by the squeezing of the skin in between the bony prominences and the resting surface, usually a bed, chair, or wheelchair. One of the chief strategies for preventing the onset of bed sores is the relief of pressure through frequent turning and repositioning through the use of pressure-relieving or other protective devices.
Bed sores are a significant issue in the long-term care industry and are a specific focus in the care planning process. During the care planning process, the risks to the health and well-being of the resident are identified, and a series of specific steps, or interventions, are developed to address those risks and then assigned to various members of the staff to carry those out on a day-to-day, shift-to-shift basis.
The resident at issue has severe cognitive impairments and quadriplegia with spasticity. She was bedbound and her lower legs were contracted due to inactivity. One of the complications that results from a nursing home resident developing contractures is that the legs lay on the bed differently than they might otherwise, exposing different portions of the legs to pressure than might be the case if the resident was laying flat in bed. In this case, the way that the resident’s legs lay on the bed resulted in her inner ankle resting on the bed.
To address the risk of the resident developing pressure ulcers to the ankle, there was a physician order in place for use of protective boots. Use of these boots was incorporated into the resident pressure ulcer prevention care plan. Between the order and the care plan, it was incumbent on the staff to make sure that the protective boots were used with regard to this resident. However, the facility wound care nurse told the state surveyor that these were used for the resident until after the bed sore on her ankle developed.
Due to the failure of the staff to use the protective boots, the skin on the resident’s inner ankle was exposed to pressure (from her unusual lying position) and friction (associated with her spasticity), all of which led to the development of a Stage 4 bed sore on the resident’s ankle. A wound care physician had to be brought into the nursing home to treat the resident, including doing a surgical debridement of the wound. This was the exact scenario that the care plan and the physician order were intended to prevent.
When interviewed by the state surveyor, the Director of Nursing admitted that there was a problem with residents developing bed sores in the facility. She further admitted that the skin assessments were being done only weekly by a wound care nurse and that rather than doing doing daily skin assessments, the floor nurses had been instructed to give the resident’s skin “a good look.” When pressed as to why this resident did not have the protective boots on, she also admitted that there were issues getting the staff to implement physician orders or care plans intended to prevent the development of pressure ulcers. The fact that this is occurring at scale in this nursing home is a massive failure of the care that the residents at this facility are entitled to.
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