IDPH has cited and fined St. Anthony’s Nursing & Rehabilitation Center in Rock Island after a resident there was required to undergo surgery due to worsening in the condition of the sore.
Bed sores or pressure ulcers are a major focus of care in the long-term care industry. The development and/or decline of a bed sore is a serious health event in the course of care for a nursing home resident, often leading to other complications.
Federal regulations relating to be sores provide that when a resident enters the nursing home, they should receive care consistent with professional standards necessary to prevent the development of bed sores. The regulations further provide that once a resident develops bed sores, they must receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new wounds.
Once a resident develops a bed sore or a bed sore declines, two things must happen. First, the doctor must be notified so that new treatment orders must be carried. Second, the care plan must be evaluated and likely revised. Both the doctor’s orders and the steps outlined in the care plan must be carried out on a day-to-day, shift-to-shift basis.
The resident at issue was admitted to the nursing home with a Stage 4 bed sore measuring 3×3.5 cm with a depth of 1.7 cm. Over the course of a month, the wound declined in that it grew in size to 10×8 cm with a depth of 3.5 cm with necrotic tissue in the wound bed and involvement of the fascia. At that point the resident was transferred to the hospital to undergo surgery to remove the dead tissue.
How did things go so badly for this resident? The answer, as is often true with bed sores, was in many ways:
- The Stage 4 bed sore that he was admitted with was not addressed in the resident care plan. In addition to physician orders, there are a number of nursing interventions that can be taken to improve the resident’s chances of healing. Without having those steps included in the resident care plan, having those things done is left to chance.
- The physician orders were not followed. The initial orders were for dressing changes once per day, but then were changed early in the second week that the resident was there to twice daily. The changed orders were not reflected on the Treatment Administration Record, so the resident only got dressing changes daily – on the days that there were dressing changes at all – and there were days when there were no dressing changes at all. Skin audits that were ordered were not done. Measurements were not taken regularly of the wound.
Bed sores are a different kind of injury than those that might be sustained in a nursing home fall or a nursing home choking accident in that there is usually not a clearly defined time when the injury took place. Instead this is an injury which really reflects the cumulative effects of breakdowns in the delivery of care. The records here show that there are small breakdowns in the care happening over and over – and as a result this resident’s bed sore decline swiftly to the point that surgery was needed.
The real question is of course why these breakdowns happen, and the answer frequently comes back to this being an understaffed nursing home. The staff in understaffed nursing homes have a hard time keeping up with basic needs of the residents, and this has a direct impact on the residents. Unfortunately, understaffing the nursing home is a key component 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.
Other blog posts of interest: