Sharon Health Care Willows resident undergoes surgery for bed sore

IDPH has cited and fined Sharon health Care Willows nursing home in Peoria after a resident there developed a bed sore on his buttocks which declined to the point that it required surgery and treatment with IV antibiotics.

Federal regulations provide that when a resident enters a nursing home without having a bed sore, he should receive care, treatment and services such that the resident will not develop them unless they are clinically unavoidable. Further, once a resident does develop a bed sore, he must receive care, treatment and services necessary promote healing, prevent infection, and prevent the development of new sores.

Because they are so specifically addressed in the federal regulations, prevention of bed sores is a specific area of focus in the care planning process at every nursing home. The care planning process begins with an assessment of the resident’s skin condition and then their risk of developing beds sores, most often using a standardized risk assessment tool called the Braden Scale. If a resident has bed sores or is at risk for developing bed sores, a care plan is developed which includes a series of steps that are to be taken to reduce the risk of having a resident actually develop bed sores. That pressure ulcer prevention care plan must then be communicated to the staff who then must carry it out on a day-to-day, shift-to-shift basis. Finally, the care plan must be evaluated on an ongoing basis to see whether it is effective in practice or whether it is meeting the care needs of the resident, taking into consideration any changes or declines in the resident’s condition.

Aides are responsible for regularly checking the skin of the residents they care for while dressing them, providing incontinence care, or giving showers. If they identify an area of skin breakdown, it is their job to alert the nurse. Nurses are also responsible for periodic skin checks as well. if a skin breakdown is identified, it is the nurse’s job notify the doctor of the bed sore so that the doctor can enter orders for treatment. Further, the development of a bed sore or the decline of an existing one is an event that requires revision of the care plan.

This citation tells the story of what happens when there are multiple breakdowns in this process because staff members do not know what their responsibilities are.

When the resident at issue was admitted to the nursing home, he had no skin breakdowns. This means that he should not have developed any unless they were clinically unavoidable. A Braden assessment was performed which showed that he was at moderate risk for developing bed sores. Even though the resident was at risk, no pressure ulcer prevention care plan was put into place. A well-thought out care plan would have included a turning and repositioning schedule, use of pressure relieving device, use of barrier creams, and regular skin inspections.

Just over two weeks before the resident was sent to the hospital, an aide discovered a skin breakdown on the buttocks. However, none of the aides reported the skin breakdown to the nurse. The treatment nurse was responsible for doing weekly skin inspections. However, she never identified the area of skin breakdown because the resident was in a low bed (as a fall prevention measure) making it difficult to see the area of the buttocks where the skin breakdown occurred, which was in between the folds of the buttocks. The treatment nurse further reported to the state surveyor that the skin checks which were supposed to be done each shift by the aides was documented as being done, but were not in fact done, and on other shifts the skin checks were not completed at all.

A week before the resident went to the hospital, the treatment nurse did a quarterly reassessment of the resident’s Braden score to measure pressure ulcer risk. This showed that the resident’s condition had declined and was now at high risk – notwithstanding the fact that resident already had a bed sore that she was unaware of. Of course, the resident’s condition had probably declined to the point where the resident was at high risk well before that, but that did not trigger any of the nurses on the floor to suggest revision of the care plan.

Even though the treatment nurse now recognized that the resident was at high risk for skin breakdowns, she did not revise the care plan. She expected that the care plan coordinator would revise the care plan. The care plan coordinator acknowledged getting the Braden scores showing that the resident was now at high risk, but told the state surveyor that she didn’t know what to do with them.

On the day that the resident was sent to the hospital, the treatment nurse was helping an aide clean up the resident after an episode of incontinence. While she was doing so, she saw two necrotic areas on the resident’s buttocks. She alerted another nurse and they contacted the doctor who ordered the resident sent to the hospital.

T o summarize the areas where the care of this resident broke down, we have:

The resident was assessed as being at moderate risk of skin breakdown, but no care plan was put into place.
Multiple shifts in which skin inspections were supposed to be completed by aides which were not done or which were documented as having been done but were in fact not done.
When the skin breakdown was discovered it was not reported to the nurse by the aide who discovered it, nor by multiple other aides during later shifts over the next two weeks plus. Due to the failure of the aides to notify the nurses, the doctor was not notified of the skin breakdown for over two weeks, resulting in a delay in the resident receiving the care he needed.
The skin breakdown was not noticed by the treatment nurse during her weekly skin inspections for at least two weeks, in part due to the resident being in a low bed which made seeing the wound difficult.
The resident’s condition declined to the point that he was at high risk for skin breakdowns, yet none of the nurses recognized that this was the case so as to suggest revision of the care plan based on the change in his condition.
The treatment nurse conducted a Braden assessment without recognizing that the resident already had a skin breakdown.
Once the Braden was done showing that the resident’s risk of skin breakdown had increased from moderate to high risk, there was still no revision of the care plan.

So – what was the consequence of all this?

The resident was brought to the hospital, where the wounds were assessed as being Stage 4 bed sores. Surgery was performed, and the resident was started on IV antibiotics because there was evidence that the infection of the soft tissue had worked its way into the bone (osteomyelitis). These wounds would not have necessarily progressed to that point with proper steps being taken to prevent the bed sores or with the timely initiation of treatment for these wounds.

The failure of the aides, the treatment nurse, and the care plan coordinator to recognize what their roles are in the prevention and treatment of bed sores speaks to a nursing home which fails to invest in the training of its staff. Unfortunately, failing to make this kind of investment in the people who work for them is common in the nursing home industry. 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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