IDPH has cited and fined Avatara of Elgin nursing home after a resident there developed a bed sore after the staff failed to take basic preventive measures after admission.
There are a handful of factors that place a resident at risk for developing bed sores. The most prominent of these is immobility. To combat that risk factor, putting residents who are incapable of respositioning themselves on a turning and respositioning schedule is a mainstay for pressure ulcer prevention.
The resident at issue was admitted to the facility with no pressure ulcers. This means that under federal regulations, the resident was entitled to care, treatment, and services necessary to prevent bed sores and should not develop them unless they are unavoidable. There are certain medical conditions which may result in a truly unavoidable bed sore. Among these is suffering from cancer.
When the resident was admitted, he had a number of diagnoses which placed him at risk for developing bed sores, including hemiplegia (near paralysis on one side, usually the result of a stroke), malnutrition, suffered from incontinence of bowel, and was receiving radiation therapy for prostate and bladder cancer. These are factors which placed the risk at high risk for developing bed sores.
The resident was properly assessed as being at risk for developing bed sores, but the floor staff was advised that turning and respositioning was required for this resident. The assessment is only the first step in the pressure ulcer care planning process. From there, an actual care plan has to be developed and then communicated to the staff actually charged with caring for the resident. This is an obvious point of breakdown in the delivery of care for this resident – either a written care plan was never developed or was never communicated to the staff.
The net effect? The resident developed an unstageable pressure ulcer to the coccyx. The wound was cultured and shown to be growing out drug-resistant organisms. The resident was sent to the hospital for further treatment.
There was an obvious breakdown in care here which had serious consequences for a medically fragile resident. This resident was at very high risk for developing bed sores because of the underlying medical problems he had, but was never given even a fighting chance because of the breakdown in the delivery of care. Making matters worse, the fact that the wound culture grew out drug-resistant organisms is a grim finding because patients undergoing chemotherapy for cancer already have highly compromised immune systems.
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