In a certification survey dated August 10, 2012 and corrected September 30, 2012, the Department of Health found that Providence Rest, a Bronx nursing home, failed to properly prevent and treat a resident's pressure ulcer (pressure sore, bedsore). The DOH found that it was an isolated with the potential for more than minimal harm.
As this blog has discussed in the past, a facility must ensure that a resident does not develop pressure ulcers unless his or her condition makes the development of such an ulcer unavoidable. Further, if a resident has a pressure ulcer, he or she must receive proper treatment to heal the sore, prevent infection, and prevent additional pressure sores from developing.
The resident discussed in the DOH study displayed several traditional risk factors for the development of pressure sores. She was ninety-six years old, suffering from dementia, chronic kidney disease, and incontinence of bowel and bladder. The resident needed assistance in all areas of daily activity. Initially, she had no pressure ulcers, and because of her risk factors, a care plan was in place to prevent their development. The resident developed a Stage II ulcer in March of last year. In the notes and records for the months leading up to this discovery, there was no documentation of the presence of a Stage I ulcer in the resident's chart. Ultimately the ulcer deteriorated to a Stage III. When probed by the DOH, the facility could not answer why the pressure ulcer was not reported at first notice, which may have prevented or stunted further deterioration.
Obviously prevention is the best way to deal with pressure sores. Diligent adherence to an individualized care plan can prevent pressure ulcers before they develop. Should this fail, however, early detection and treatment is essential. As pressure sores deteriorate, the health risks to the resident (including infection and death) increase, as does the pain associated with both the sore and its treatment. A facility must closely monitor for skin breakdown, particularly in residents known to be at risk for the development of pressure ulcers. Negligently allowing a sore to develop can have dire, even fatal, consequences.
Additional violations found at Providence Rest during this inspection cycle include failure to properly label drugs and biologicals; failure to properly provide drugs and biologicals; and failure to provide necessary care for the highest practicable well-being. The details of the report can be found on the Department of Health website, or by clicking here.