IDPH has cited and fined Aperion Care of Forest Park after a resident there bled to death following the removal of a wound vac device.
Many nursing home residents take anticoagulant (or blood thinner) medications to prevent serious medical issues such as a stroke, heart attack, or pulmonary embolism, all of which can be fatal or cause serious, long-lasting, debilitating problems. They work by inhibiting the blood’s ability to form clots. The risk and the downside of taking these medications is that by inhibiting the blood-clotting ability of the body, when the resident experiences a bleed, it may go unchecked which can cause its own serious set of problems. This is one of the reasons that residents on anticoagulants require close monitoring after experiencing a nursing home fall – they may be experiencing a brain bleed which can prove fatal or seriously debilitating if allowed to continue.
The resident at issue was admitted to the nursing home after undergoing a vascular bypass surgery on January 8 to improve circulation to the left lower extremity. During the hospital admission, he also underwent amputation of the fourth and fifth toes of his left foot. There were orders in place for continuous use of wound vac to help close a non-healing wound where the toes had been amputated. The resident was also taking aspirin and Plavix to help prevent blood clots. The resident was to return to see the doctor on the morning of January 23.
The practice at the nursing home was that when a resident had an early morning doctor appointment, the wound vac would be removed the prior afternoon. This was because if the medical transport team arrived to take the resident to the doctor’s office before the wound care nurse arrived at the nursing home, there was a risk that the resident would be admitted to the hospital from the doctor’s office and the wound vac machine might not be returned to the nursing home. Therefore, to avoid the risk of loss of the wound vac machine, the wound vac would be disconnected the afternoon before the appointment at the doctor’s office.
On the afternoon of January 22, in keeping with the practice at the nursing home, the wound care nurse removed the wound vac and applied a dry dressing before leaving for the day. She told the state inspector that there was no active bleeding when she left the resident. However, less than an hour later, a staff member observed a pool of blood on the floor coming from the wound where the toes had been amputated and the resident was unresponsive and in cardiac arrest. 911 was called and the resident was brought to the emergency room, but the staff there was unable to revive the resident and he was declared deceased.
The state investigation revealed that the facility had no policy in place for monitoring residents after removal of the wound vac. Further they relied on representatives from the various manufacturers of the different types of wound vacs in use at the nursing home to train the staff, but they were unable to show what training had in fact been provided to the staff, although the operations manual to the wound vac called for special precautions for residents who are on anticoagulants.
Making matters worse, the resident’s doctor said that the wound vac should not have been removed to begin with, as his order was for continuous use and removing the wound vac denied the resident of the additional hours of treatment with it. He told the surveyor that the removal of the sponge that covered the wound when the wound vac was disconnected could have caused the bleeding which resulted in the death of this resident.
What this shows is that the nursing home did not train or have policies in place on monitoring residents after a wound vac was removed, but removed the wound vac in violation of doctor’s orders in order to guard against the possible loss of the wound vac in the event that the resident was admitted to the hospital from the doctor’s office. Good for the nursing home, not good for the resident, even without the tragic and avoidable outcome that we had here.
The practice of removing the wound vac to guard against the risk of it being lost is an example of how dollars and cents decisions adversely effect care for nursing home residents. 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: