A New York State Department of Health certification survey dated April 8 of last year cited Northern Riverview Health Care Center, located in Haverstraw, NY, for failure to provide proper treatment to prevent/heal pressure sores (bedsores, decubitis ulcers). The findings discuss the development of pressures sores in no fewer than five residents of the facility.
The findings detail a pattern of miscommunication between physicians, nurses, and nurse aides throughout the facility. One resident, referred to in the survey as Resident #18, was admitted to the facility on Christmas Eve, 2008 with risk factors noted for the development of pressure sores, although the resident's skin was intact at the time of admission. Although the resident was confined to a wheelchair, no evidence was readily available to prove that interventions were taken to prevent pressure ulcers to the resident's buttocks. As a result, the resident did, in fact, develop a Stage I pressure ulcer on the left buttock on or around November 15, 2009. Over the next two and a half months, through February 2, 2010, the ulcer deteriorated to a Stage IV pressure ulcer. This is a violation of 10 NYCCR 415.12(c)(2), which states that a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.
Unfortunately for both Northern Riverview and its residents, Resident #18 was not the only occupant to experience the development and/or exacerbation of pressure sores. Delays in diagnoses, incomplete/unfollowed care plans, and unapplied interventions led to the development of pressure sores in at least four other residents at the facility.