IDPH has cited and fined Victorian Village Health & Wellness nursing home in Homer Glen after a resident there developed a pressure ulcer on her heel from her orthotic boot.
“Pressure ulcers” are commonly referred to as bed sores because they frequently develop on persons who are unable to get out of bed and are caused by pressure from the weight of the body against the bony prominences. This is why some of the most common parts of the body for bed sores to develop are the buttocks, hips, sacrum, and heels.
However, pressure from the weight of the body is not the only way that pressure ulcers can develop. One common way for bed sores to develop is pressure against the body from medical devices and equipment such as casts, catheters, immobilizers. The risk associated with the use of these devices is well-known in long-term care industry and should be addressed in the care planning process. The risk from these devices can be mitigated by frequent skin inspections; checking the device for fit, condition, and positioning; and obtaining doctor orders permitting removal when appropriate.
The resident at issue was admitted to the nursing home for rehabilitation after suffering a fall at home. One of the complications that she had as a result of the surgery was that she had a drop foot on one side for which she was given an orthotic boot to wear. On admission to the nursing home, she underwent a full skin inspection and there were no pressure ulcers.
After being admitted to the nursing home, she would periodically complain of a burning sensation in the heel. However, no one would take the boot off to inspect the underlying skin or the condition of the boot; they would simply loosen the boot for a period of time. Further, no one notified the doctor that the resident was complaining of a burning sensation in the heel.
The pressure ulcer was not discovered until the resident had been admitted to the nursing home for about 10 days, at which point a staff member removed it to clean the foot. At this point, the wound was considered an unstageable pressure ulcer which is by definition at least a Stage 3 or possibly a Stage 4 pressure ulcer. According to the citation, the wound had extended up to the Achilles tendon of the resident.
Why did the resident develop the pressure ulcer? Inspection of the boot revealed that even though it was lined, a portion of the lining had worn away so that the heel of the resident was laying directly on the frame of the boot. This is exactly the kind of thing that causes pressure ulcers to develop with the use of medical devices and equipment – prolonged pressure from an inadequately padded device.
What should the nursing home have done? For starters, the regular inspections of the skin and the device were not done. Had the boot been removed and the condition of the skin and the boot been observed, the relationship between the resident’s complaints about a burning sensation in her heel would have been readily apparent. Beyond that, the frequent appearance of a burning sensation in the heel also should have resulted in physician notification. This was not done.
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