IDPH has cited and fined Elevate Care of South Holland nursing home after a resident there died as a consequence of an infection of his dialysis fistula going untreated.
One of the basic truisms of care in a nursing home is that doctors are not present in a nursing home 24/7 the way that they are in a hospital. Therefore, in the absence of physicians being in the building, nurses must act as “the eyes and ears” of physicians with regard to the residents who are under their care. In that role it is part of their job to notify physicians of changes in the condition of the residents who are under their care as well as events such as the development of bed sores, medication errors, choking incidents, and falls. After a doctor is notified of one of these things, the doctor has the option to issue orders for care over the phone, come into the nursing home to see the resident, or order the resident sent out to the hospital.
One of the types of conditions that nurses must notify doctors about is the onset of signs and symptoms of infection. Nurses do not need to know whether what they are seeing is actually an infection, what kind of infection it is, or how to go about treating it – although experienced nurses often have a solid idea about all of these issues. The most common course of action is to start an antibiotic and to obtain a relevant culture (for example, a urine culture if a urinary tract infection is suspected) to confirm the presence of the infection and whether the antibiotic ordered is appropriate for the type of infecting organism.
The resident at issue was a dialysis patient and had an AV fistula (the port through which dialysis is done) on his right upper arm. The facility wound care nurse performed a routine readmission skin assessment on the resident and saw that there was purulent drainage coming from an abscess on the right upper arm. The wound care nurse notified the resident’s nurse practitioner via text message and advised her that there was a wound with some drainage and that a wound culture had been obtained. The wound care nurse also claims to have notified the wound care physician, but according to the citation, he denied knowing about the abscess until he was in the facility three days later.
The resident was scheduled for dialysis the following day but did not receive it for reasons that are not clear from the citation. However, the nephrologist stated that had he been made aware of the presence of an abscess near the dialysis fistula, he would have obtained a wound culture and started an IV antibiotic through the dialysis fistula immediately.
The wound care physician arrived in the nursing home three days after the abscess was first noted. He ordered Keflex, an oral antibiotic, and a consult with an infectious disease physician. However, the nursing home did not have the antibiotic in stock and when they attempted to reach the infectious disease doctor, they only reached his answering service. The antibiotic did not get delivered before the resident was sent to the hospital. Therefore, neither of the orders were actually implemented before the resident was sent to the hospital the following morning.
The next morning the nurse on duty recognized that the resident’s condition was declining and his vital signs were troubling, so she called 911 to have the resident sent to the hospital. The preliminary diagnosis there was that he suffered a stroke, so an MRI of his brain was ordered and this should evidence of septic emboli and a cerebral abscess – signs that the infection had migrated to his brain. It was determined that he had a poor chance of neurological recovery and that he was a poor surgical candidate, so the family opted for comfort measures only, and he died five days later.
There are a number of issues with the care that this resident received:
- The skin assessment where the abscess was discovered was a readmission assessment. Where was he being readmitted from and why was the infection not addressed there? The citation does not give any indications on this issue.
- It is unclear whether the wound care physician was in fact notified of the presence of the infection – the wound care nurse from the nursing home yes, the doctor says no. There are a number of ways of resolving that issue. One way would be to see who issued the orders for the wound culture and dressing. Otherwise it becomes an issue of getting into phone records and the electronic medical record if it had a electronic messaging platform integrated with it.
- Assuming that both the nurse practitioner and the wound care doctor were timely notified, the discussion ended without an order for an antibiotic. An experienced nurse would have recognized that the usual course is to initiate antibiotics before the results of the culture are received. In her role as a patient advocate, the nurse should have asked whether they wanted one started.
- There were no clear lines of responsibility for who was managing this portion of the patient’s care. It is a common adage that when everyone is responsible, no one is responsible. Sadly, no one appears to have taken charge to ensure that the resident had an antibiotic started.
- It appears that the resident did not go to dialysis as scheduled the day after the abscess was discovered. The dialysis fistula is something that directly impacts the care that a nephrologist gives, but no one alerted the nephrologist about the apparent infection in the area. It is clear from the citation that the nephrologist would have addressed the abscess with a good deal more urgency than either the wound care physician or the nurse practitioner.
- When the antibiotic was ordered but not available, no one advised the wound care physician of this. Many nursing homes carry a “house stock” of commonly used medications, and the one ordered would have likely fallen into that category. When it was not available, the failure of the staff to notify the wound care doctor that they could not give the antibiotic as ordered denied the wound care doctor the opportunity to choose a different course of action – such as a different medication or ordering the resident to the hospital. When an infection is left untreated, it can only be expected to worsen the in medically compromised population found in nursing homes.
This series of failures in the care that the resident received ultimately ended up causing his death.
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