IDPH has cited and fined Willow Rose Rehabilitation & Health nursing home in Jerseyville after a resident there developed an unstageable pressure ulcer to the heel.
Bed sores are also called pressure ulcers or pressure sores because one of the main things that cause these wounds is pressure on the small blood vessels which supply the skin, usually from the weight of the body between a bony prominence such as the hips, heels, or tailbone against a resting surface. One of the main strategies for combating the development of bed sores is pressure relief through the use of pressure relieving devices and a turning and repositioning schedule. Pressure relief is also a mainstay for helping nursing home residents heal from bed sores once they develop.
Federal regulations require that once a resident develops a bed sore, they receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new sores. In order for that to happen, regular skin checks need to be performed so that once a resident develops a bed sores, the nurse can notify the doctor to obtain orders for treatment. This also allows treatment to begin before the wound has declined to Stage 3 or Stage 4 bed sores or becomes an unstageable pressure ulcer.
The staff noted the discovery of an unstageable pressure ulcer on the resident’s heel on June 25. The nurse on duty contacted the doctor who issued orders for treatment. However, those treatment orders were not transcribed onto the Medication Administration Record, so the treatment orders were not carried out until July 1, when they started a new Medication Administration Record page in the resident chart.
Another part of the resident chart was the Skin Inspection Report which did not note the presence of the bed sore on the residents heel at all- even after it was noted in the chart elsewhere.
While the state surveyor was in the facility, she observed that the resident was not moved in bed for a 3.5 hour period even though her care plan called for being turned and repositioned every 2 hours.
When interviewed by the state surveyor, the resident’s doctor stated that he expected that the bed sore would have been discovered before it became unstageable. The administrator was unable to offer an explanation as to why the bed sore was never noted on the skin inspection report and acknowledged they had trouble maintaining the every two hour turning and repositioning schedule.
As a whole, this is a facility which has a series of failures which will likely lead to more residents developing serious bed sores. They are not maintaining the 2 hour turning and repositioning schedule, not accurately completing skin inspections, not getting orders for treatment onto the resident’s chart, and not delivering the care needed to allow residents to recover from the bed sores. This series of failures is setting up residents for getting bed sores, letting them decline, and putting residents at risk for developing infections like cellulitis and osteomyelitis.
These kinda of failures are not a one-off event, but are happening repeatedly, which is a sign of an understaffed nursing home. Sadly understaffing is one of the features 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.
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