IDPH has cited and fined Stephenson Nursing Center nursing home in Freeport after a resident from that nursing home had a bed sore decline due to bad care that the resident required surgery to treat it.
There are three main factors which place a resident at risk for developing bed sores: immobility, incontinence, and poor nutritional status. A resident’s risk of developing bed sores is supposed to be addressed through the care planning process. Once a resident develops bed sores, this is an event which requires physician notification and a revision of the resident care plan, as federal regulations relating to bed sores require that once a resident develops a bed sore that the nursing home provide care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new sores.
When this resident was admitted to the nursing home, he did not have bed sores. This meant that he was entitled to receive the care necessary to prevent the development of bed sores unless they were clinically unavoidable. Although the citation does not recite what his Braden score was, he was very clearly at risk for developing bed sores, as he suffered from quadriplegia and neurogenic dysfunction of the bladder, which means that he was immobile and incontinent. When the care planning process is implemented properly, a resident such as this would have had a care plan put into place once the resident was determined to be at risk for developing bed sores. However, this was not done until four and a half months after the resident’s admission and over a month and a half after the first bed sore developed.
The first bed sore, located on the left buttocks, was noted approximately 3 months after the resident entered the nursing home and about two months before he was eventually sent to the hospital. The resident’s doctor was notified but the care plan was not changed to reflect the fact the resident’s had greater care needs due to the onset of this new bed sore. Over the course of the next month and a half, the wound continued to decline, growing larger in diameter and gaining additional depth with necrotic tissue appearing in the wound bed. The continuing decline of the bed sore is also something that called for physician notification, as that indicates that the care which was being provided was not successful in resolving the bed sore. The treatment orders were not changed at all until about two and half weeks before the resident went to the hospital.
At the same time that the condition of the bed sore was declining, the resident was experiencing significant weight loss. This means in addition to having immobility and incontinence as risk factors for bed sores, he also now had poor nutrition to go along with this. Having good nutrition is important for preventing bed sores but is really crucial when attempting to heal a pressure ulcer. How significant was the weight loss? According to the citation, during period beginning just over two months before he was admitted to the hospital up through the date he went to the emergency room, the resident’s weight dropped from 240 pounds t0 212 pounds. Part of that was due to the loss of a tooth and difficulty eating associated with that, but the bottom line is that this resident was not receiving the intake of nutrients necessary to recover, and contrary to facility policies, his intake was not tracked for the vast majority of the meals that he was served.
It is also worth noting that the nursing home recorded his weight as being 235 pounds only four days before he went to the hospital. Obviously, that is an example of false charting. Being able to pinpoint examples of false charting in a nursing home chart is valuable in nursing home abuse and neglect lawsuits because the presence of false chart entries undermines the reliability of other chart entries which tend to reflect that care was provided in the right way and undermines the credibility of the individual staff members.
On the day the resident was sent to the emergency room, he told the staff that he was dying and asked to go to the hospital. Permission was given by the attending doctor, and he was brought to the hospital. There, his blood sugar level was taken and it was 407, a severely elevated blood sugar level. Elevated blood sugar levels are often associated with the presence of an infection. Inspection of the skin revealed a second bed sore, this one on his sacrum, which measured approximately 2 cm in diameter but was bone deep. The left buttocks wound was 10×13 cm with 2 cm of depth. About half of the surface area of the buttocks ulcer was necrotic. He underwent surgery to debride both of the bed sores. He was diagnosed with osteomyelitis at the location of the sacral wound. This ordinarily would have been addressed surgically, but he was not a surgical candidate, so the doctors were going to try to bring the infection under control with antibiotics.
The level of failure in the care of this resident is staggering. Here is a short rundown of the failure of the care that this resident endured:
- He was on obvious risk for developing bed sores based on his immobility and incontinence. Yet, there was never a pressure ulcer prevention care plan developed for him.
- Once he did develop the left buttocks wound, the care plan was never revised to include the care needs associated with attempting to heal an existing pressure ulcer.
- The resident suffered significant weight loss during the period of his residency at this nursing home. At a time when his nutritional needs were at their maximum level to sustain wound healing, he was likely suffering from malnutrition.
- The left buttock wound continued to decline, but the doctor was not notified that the treatments he ordered for the resident were not effective and the wound was getting worse, not better. Similarly, there was nothing done until the very end with regard to care planning for pressure ulcer healing.
- The facility staff failed to recognize the presence of the sacral wound at all. As a result there were no treatment orders obtained and no revisions made to the care plan to account for this new bed sore.
- The wounds became infected, but the staff failed to recognize signs and symptoms of the infection and failed to notify the doctor, delaying the start of care allowing the infection to progress.
- The family was not notified about the declines in the resident’s condition.
These are only the very high-level failures in the care that this resident received. A detailed review of the resident chart would likely show dozens of individual failures of the care of this resident.
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