IDPH has cited and fined the Aperion Care of Bradley nursing home after a resident there had a bed sore worsen from a Stage 2 to a Stage 4 bed sore which became infected.
There are two basic federal regulations which relate to the issue of bed sores or pressure ulcers. The first of these relates to what is required when a resident enters a nursing home without having any bed sores. It requires nursing homes to provide care, treatment, and services consistent with professional standards to ensure that a resident does not develop a pressure ulcer unless it is unavoidable. The second of these relates to what happens after a bed sore develops. It requires the nursing home to provide care, treatment, and services to promote healing, prevent infection, and prevent the development of new sores.
The second of the two regulations is what was at issue with this citation.
When a resident develops a new bed sore has one decline (go from a Stage 2 to a Stage 4 bed sore, for example), this is a significant change in condition. It requires revision of the resident’s pressure ulcer prevention care plan and is something that requires physician notification. The reason that the doctor must be notified when there is a new or worsening bed sore is that this allows the doctor to issue new orders for treatment, refer the patient to a specialist, or have the resident sent to the hospital for care.
This resident developed a bed sore to his left heel, Stage 2-3, measuring 3 x 3 cm with a dark center to it. The staff promptly notified the doctor, who issued orders for treatment. However, the wound care nurse discontinued the treatment orders two days later. The reason: she thought that the order was in error because she was unaware that there was a wound on the left. There was already a wound on the right side and no one told her about the new wound.
The net effect of this is that the wound went untreated for a month and worsened from a Stage 2 or Stage 3 bed sore to a Stage 4 bed sore (exposed muscle or bone). During that time, none of the staff questioned why the resident was not getting treatment for a wound that they knew about it; no one notified the doctor of the ongoing decline in the wound.
Even after treatment orders were restarted, the wound continued to decline and became infected. The resident was transferred to this hospital with an infection of the soft tissues (known as cellulitis) and a likely infection of the bone (known as osteomyelitis).
There are obvious significant issues with the care that this resident received. There is likely some liability on the part of the wound care nurse (who may be an independent contractor and not a direct employee of the nursing home) for discontinuing necessary orders for treatment. That does not relieve the nursing home completely of liability, as no one raised the issue that a resident with a bed sore on his heel was not getting the care that he needed. It also appears that the nursing staff failed to bring the further decline of the bed sores to anyone’s attention.
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