IDPH has cited and fined McLean County Nursing Home in Normal after a resident there developed bed sores on both heels which worsened due to improper care after the wounds were discovered.
The resident at issue was admitted to the nursing home without any pressure ulcers, but had mobility deficits which left her chairfast and which required that the staff provide asisstance with respositioning. Approximately two weeks after admission, there were blisters discovered on both heels. The staff alerted the doctor who ordered that the resident not be placed in closed heel shoes, that the resident use pressure relieving boots, and that her heels be floated while she is in bed.
After a nursing home resident develops a bed sore, the next steps that must be taken are to notify the resident’s doctor to obtain orders and to update the resident care plan. Part of the care planning process is to communicate the changes to the care plan to the staff responsible for delivering the care to the resident. After all, a great care plan is of no use if the people charged with carrying it out do not know what it is.
This facility used a computerized system which assigned tasks to aides through the POC or Point of Care system. By reviewing the tasks for each reisdent through the POC system, the aides would know what care to provide. This is a very reasonable system …. as long as it is actually implemented. And that is where the care for this resident broke down.
Over the course of the two and half months that followed the discovery of the blisters on the resident’s heels, these wounds declined to a Stage 4 pressure ulcer on one heel and a Stage 3 on the other. When the surveyor arrived in the facility, she saw that the resident was wearing closed heel shoes, that she was not using presaure reliving boots, and that her heels were not being floated (lifted off the surface of the bed) when she was lying down in bed.
Federal regulations require that once a nursing home resident develops pressure sores, they are entitled to receive care treatment, and services to promote healing, prevent infection, and prevent the devlopment of new sores. That didn’t happen here. The resident had orders which in essence called for pressure relief on the heels and because the substance those orders was not incorporated into the care plan because the nurse whose responsibility it was to do this simply failed to do so. A simple breakdown in the process with a serious result.
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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