IDPH has cited and fined Generations at McKinley Place nursing home in Decatur after a resident there developed a pressure ulcer to her calf.
As people age, they become more susceptible to suffering fractures in falls. At times they suffer fractures which would be repaired surgically in a younger person, but due to their surgical risk profile and lack of mobility, the course of treatment consists of immobilizing the fractures. In the past, this would normally be done with a cast, but is more often done now with a removable device which immobilizes the fracture site allowing the fracture to heal while at the same time allowing the device to be removed to allow for skin care and to start rehabilitation.
The problem with stabilizing devices like boots and immobilizers is that by their very nature, they are intended to hold the fracture in place and as a result, create pressure. “Bed sores” are also called pressure ulcers because one of the main factors that produce bed sores is pressure on the skin between a bony prominence (such as the hips, buttocks, heels, or tailbone) and a resting surface (such as a bed or chair). This is why prolonged exposure to pressure as a result of immobility is one of the main risk factors for developing bed sores. Devices such as boots or immobilizers create a risk of developing pressure ulcers in much the same way, except the pressure point is between the skin and the device. This requires regular removal of the device and inspection of the skin for early signs of skin breakdown.
This resident was an immobilizer after suffering a broken foot. Initially, the fracture was casted. Then, during a follow-up office visit a small scabbed area (1×2 cm) to the back of her calf was noted, so the doctor switched her into a brace, applied a dry dressing, and ordered that the nursing home staff do daily skin checks and dressing changes. The orders from the orthopaedic surgeon were never entered into the resident chart. Skin checks would ordinarily be performed at the time that the resident received a shower, but this resident was exclusively receiving bed baths. As a result, there were no dressing changes and no skin checks done.
Approximately five weeks after the resident was placed into the immobilizer, an aide reported that there was an odor coming from the resident’s leg. When the nurse came to find out what the source of the odor was, he removed the immobilizer. This revealed an unstageable pressure ulcer measuring 9.5 cm long, 5.5 cm wide and 1.5 cm deep with obvious signs of infection. The resident was sent to the hospital where she underwent surgical debridement of the pressure ulcer. The doctors there believed that the wound was caused by the immobilizer and that had the doctor’s orders been followed, the wound would not have progressed to such an extent.
Federal regulations provide that when a resident enters a nursing home without pressure ulcers, they should not develop them unless they are unavoidable. When a resident either develops a pressure ulcer or an existing one starts to decline, this is something that requires a nurse to notify the doctor to obtain treatment orders and a revision of the resident pressure ulcer prevention care plan. When a resident has already developed pressure ulcers, federal regulations require that they receive care, treatment, and services necessary to promote healing, prevent infection, and prevent the development of new wounds.
Here, the physician orders for daily skin checks and dressing changes were not followed. Compounding this, since the resident was only receiving bed baths, she did not receive the skin checks that would happen during showers. As a result, the progression of the wound went undetected until it became so badly infected that it was malodorous.
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