IDPH has cited and fined Royal Oaks Care Center in Kewanee after a resident there developed infected bed sores on the insides of both knees.
One of the reasons that pressure sores are commonly known as “bed sores” is because on of the main causative factors is pressure on the skin between a bony prominence and a resting surface such as a bed or a chair. This is why some of the more common places that you see bed sores is on the buttocks, tailbone, hips, and the backs of the heels.
That is not the only place that you will see bed sores, and the citation that IDPH issued to this nursing home was for bed sores seen in an unusual location – in between the knees. It isn’t clear from the citation why this resident developed the bed sores in that location, but the key failure of the nursing home is what happened after the resident developed the bed sores.
After a resident develops a bed sore, federal regulations require that a resident receive care, treatment, and services to promote healing, prevent infection, and prevent the development of new pressure sores. In practice this means that the nurse must contact the doctor to let the doctor know that the resident has developed a bed sore and to obtain orders for treatment. It also means that besides carrying out those specific orders, the pressure ulcer prevention care plan must be updated to reflect the resident’s change in condition and include the steps that must be taken by the nursing staff to promote healing and prevent the onset of infection of the existing sores and to prevent the development of new sores.
One of the steps that is generally taken is that there are regular inspections of the condition of the skin, particularly during dressing changes, for signs of infection. Nurses are not required to know how to treat infections in the sense of knowing which antibiotic should be used to treat the infection, but as the eyes and ears of the doctor, they must be able to identify signs of infection so that they can notify the doctor. Cellulitis is an infection of the skin and signs of infection commonly include redness, drainage, malodor, pain, and fever. When an infection works its way down to the bone, this is known as osteomyelitis.
The resident here was noted to have flaking of the skin on the insides of both knees on May 18. On June 15, the resident’s doctor entered an order for cleansing of the wounds on the insides of the knees, application of an antibiotic ointment, and for a wound care consult. On June 22, the wounds were described as being large open wounds on the insides of both knees.
When the resident arrived at the wound care clinic on June 25, there was obvious evidence of infection. The wound care nurse treating the residnet recommended admission to the hospital because the wound required surgical debridement and IV antibiotics. The wound care nurse told the state surveyor that the wounds had been present for a month or longer and that the resident should have been treated sooner.
Without knowing more about the resident’s underlying medical issues, it is hard to fault the nursing home for the onset of these bed sores – although that is an issue I would investigate if I were the family’s lawyer. The key issue here is how the nursing staff handled the decline of the wounds and the onset of infection. The presence of the signs of significant infection and the rapid decline in the condition of the wounds should have triggered notification of the resident’s doctor so that more aggressive treatment could be initiated. This was obviously not done.
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