Facility Fails to Provide Pressure Care and Prevention for Two Residents

South Heritage Health & Rehabilitation Center was cited after failing “to provide appropriate pressure ulcer care and prevent new ulcers from developing.” After observation, interviews with staff, review of resident records, review of hospital records, and local police department photographic evidence, two residents were found to be affected.

The first resident discussed in this citation was admitted to the facility with a stage 2 pressure ulcer that wasn’t noted on her admission assessment. This pressure ulcer went untreated. After being admitted to the Emergency Room, it was discovered that she had multiple other undocumented pressure ulcers that also went untreated.

The resident was readmitted to South Heritage Health & Rehabilitation Center from a hospital visit. The Hospital Patient Transfer Form showed that the resident had Stage II pressure ulcer on her lower back. The nursing home’s readmission paperwork showed no record of the pressure ulcer or any skin issues. There was also no documentation found for the assessment of ulcers or doctor’s orders for treatment. Meanwhile, the resident complained of generalized pain.

Two days after being readmitted to the facility, the resident’s daughter called 911 after noticing her mother had multiple bruises and was unresponsive. Moments later, Police and EMS arrived at the facility.

According to EMS reports, the resident was unresponsive with no staff present in the room upon arrival. It took over ten minutes for nursing home staff to confirm the resident was not allergic to anything that would be used to treat her. The patient seemed lethargic, but opened her eyes to pain and withdrew from painful stimuli. The resident had fresh bruises on her face, underneath her left arm, and armpit. She had bed sores on her buttocks covered in the old bandage, bruises on her belly, and more red sores on her thighs. Her mouth had been caked shut with dried mucus from dehydration which prevented her from opening her mouth or communicating. After mouth care, the resident was able to communicate and answer questions.

After being admitted to the ER, the resident complained of generalized pain again but identified her mouth and buttocks as the most painful areas. Scattered bruising on the resident’s upper left arm and abdomen along with multiple stage 2 pressure ulcers were noticed when moving the resident from the stretcher to the hospital bed. The original pressure ulcer on her lower back had progressed from Stage 2 to Stage 3.

The wound dressing from five days earlier was removed and 2 new were applied. A strong urinary odor was noted during catheter change. Police were present for this evaluation and took photo evidence. An incident report was filled out for adult abuse.

Interviews with the Director of Nursing (DON), Certified Nursing Assistant (CNA), Unit Manager, and another staff member revealed that during readmission the hospital chart is reviewed during the morning meeting. In this case, the hospital chart and readmission charts did not match up, and no one recalled this resident coming back with a pressure ulcer or doctor’s orders on how to care for it. The DON stated that it was possible that the chart was not reviewed for accuracy.

Further observation revealed that another resident’s pressure ulcer dressing was 3 days overdue to be changed while the record reflected it had been changed. The dressing was also not even covering the wound.

Observation and interview with this resident revealed the he complained of heel pain and yelled out when a CNA tried to remove his sock. There were eight to ten brown stains on the bed around the area where his right heel rested. After the sock was removed, dressing on the heel showed a date of five days prior.

“Observation of the right heel revealed a round draining wound that was uncovered with serious sanguineous drainage, a scab, and raw, peeling skin.” The resident yelled out to the CNA to be careful because his heel was very sore.

An interview with the Unit Manager revealed that the dressing was not where it should be, leaving the wound exposed. The Unit Manager also confirmed that the date on the dressing showed it hadn’t been changed in 5 days. They said it had been documented as changed recently, but confirmed that the documentation was inaccurate.

Review of the facility’s policy and procedure for Wound Prevention & Treatment Overview from the Clinical Policy & Procedure Manual revealed that “resident with ulcers will receive continued preventative interventions & necessary treatment & services to promote healing & prevent infection. Wound characteristics will be documented by measuring length, width, depth in centimeters. Additional documentation shall also include color or drainage, wound bed color.”

In the case of these two residents, wound care wasn’t administered properly, and preventative measures were not taken to prevent new wounds from forming.

If you suspect nursing home abuse, contact us for a free, confidential case evaluation with no obligation to hire us. We treat our clients with compassion and aggressively represent their rights, making nursing homes take responsibility for the abuse. Distasio Law Firm has the expertise and ability to advocate for victims of nursing home abuse and neglect, even if a case goes to trial.

COVID-19 Update

During this difficult time of quarantine, self-isolation, and social distancing throughout Florida and the nation, we want you to know that there are ways to check on any loved ones in a nursing home facility. While you likely won’t be able to visit in person, below are a few tips for checking on your loved one to make sure they are getting the care they need.

  • Call every day. Set a time to catch up with your loved one, even if it’s just a five-minute call. If your loved one is tech-savvy and uses FaceTime, check-in that way! Just one call can help ensure your loved one is still getting the care you expect from the nursing home.
  • Call after each shift. Find out when each shift starts and ends, and talk to the nurses after each shift to check on the consistency and quality of your loved one’s care.
  • Find out what you can or can’t do. During this time, most nursing homes won’t permit you to enter the nursing home facility in order to protect you and your loved ones. Some, however, let families enter when the loved one is on hospice. Be sure to clarify the rules with the facility so you can plan for any situation.

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