IDPH has cited and fined Park Place of Belvidere nursing home after a resident there developed multiple bed sores.
Bed sores are a major issue in nursing homes. It is part of the data which nursing homes must report on each nursing home resident. There are specific federal regulations in place relating to the the prevention and treatment of bed sores, and the failure to meet the requirements of those regulations can result in hefty fines for nursing homes.
Bed sores are one of the areas for which specific assessments are done during the admission and quarterly care plans, usually using a standardized tool like the Braden Scale. When residents are at risk for developing bed sores, there is a pressure ulcer prevention care plan put into place. Typically, this will include an array of pressure relieving devices, such as a special mattress, special wheelchair cushion, regular skin checks during incontinence care and showers, prompt incontinence care, and a turning and repositioning schedule. Generally, bed sores will not develop immediately if there is a breakdown in the delivery of care for a few hours, but as the cumulative failures to deliver on the necessary care mount, the odds of a resident having a new bed sore increase. When a resident develops a bed sore, this is a change in condition which requires physician notification.
The resident at issue in this citation had been assessed as being at risk for bed sores for a number of reasons, including dementia, incontinence of bowel and bladder, and needing the assist of two for bed mobility, meaning being moved from side to side in bed. Despite the fact that she was at risk for developing bed sores, she was not provided with a pressure relieving mattress for her bed or a pressure relieving cushion for her wheelchair. When the time for the quarterly care plan review came up, a repeat Braden assessment was not done, and as a result no changes were made to the resident care plan.
The fact that this resident developed bed sores was first noted in the resident chart on May 1 when a discolored area was noted on the left heel and then again on May 4 where another wound was noted on the right buttocks. The facility brought in a wound care doctor on May 6 who actually noted three separate wounds including an unstageable bed sore on the right buttocks, a Stage 3 pressure ulcer on the sacrum, and an unstageable wound on the left heel. However, the daily task sheets which were completed by the CNA’s noted incontinent care every shift with no notations of skin breakdown and of the five shower sheets which were completed during the month of May through when the state surveyor came on May 16, only the discoloration on the heel was noted on May 1 only. On all of the other days, that wound and all of the others were not noted at all. The wound care doctor was recommending surgical excisional debridement of the buttocks wound.
Caring for residents at risk for developing bed sores requires ongoing diligence, including providing the right kinds of equipment and careful consideration of the resident’s care needs during the care planning process. Those basic steps were not being carried out as the resident did not have the specialized equipment necessary, nor was the Braden assessment done as part of the quarterly care planning. Breakdowns in the delivery of care routinely lead to bad outcomes for nursing home residents. Once residents have bed sores, they are entitled to the care, treatment, and services necessary to promote healing, prevent infection, and prevent new bed sores from developing. When the regular skin checks are not being done by the aides, the nursing staff and the doctors are deprived of the information they need about the resident’s progress.
In short, there were a series of systematic failures in the delivery of care to this resident which resulted in the development of these bed sores and the further decline of these wounds. This leave the resident at risk for further complications such as cellulitis and osteomyelitis. 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.
Other blog posts of interest: