New York Nursing Home Abuse Lawyer Blog

Petite Fleur, a Sayville, New York based nursing home, was cited by the Department of Health for multiple pressure sore violations in a recently released report. The survey, taken April 9, 2010, detailed a resident whose pressure ulcer (bedsore, decubitis ulcer) went undocumented until it had reached Stage 3. The resident had scored a "15" on the Braden Scale Assessment, indicating a risk for the development of a pressure sore.

Title 42 of the Code of Federal Regulations section 483.25(c) states that "the facility must ensure that (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing."

In this case, the resident was considered "at risk" as determined by on the Braden Assessment. Certainly this does not mean that development of a pressure ulcer is unavoidable. However, due to the risk factors present, the facility should have monitored the resident's skin and put a plan of care in place in order to prevent the development and/or deterioration of pressure ulcers. Failure to chart an ulcer until it has reached Stage 3, at which point there is full thickness tissue loss, is unacceptable. Additionally, the resident had already developed several other pressure sores which should have made the staff more vigilant in the resident's care and treatment.

The complete Department of Health survey can be found here.

Bellhaven Center for Rehabilitation and Nursing Care in Brookhaven, New York was found deficient by the DOH in a number of areas, according to a survey of August 8, 2011. The areas receiving less than adequate marks were clinical record keeping, accident reporting, proficiency of nurses aides, and avoidance of unnecessary catheterization.

As is often the case in these DOH deficiency reports, the study references Title 42 of the CFR. Section 483.75(l)(1) states that the facility must maintain complete clinical records for each patient, in accordance with accepted professional standards and practices. The study details two incidents at Bellhaven in which physicians ordered medication for residents, however there was no documentation that the medications were actually administered to the patients. Proper record taking is essential to the safety and well-being of nursing home residents. Quite often, a resident is unable to communicate accurately with a member of the staff. Failing to document what type of medication is administered to a patient, as well as when and where such medication was administered can lead not only to sloppy records, but sickness or death for the patient.

Section 483.10(b)(11) of the Code makes clear that: "[A] facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention." In the incident cited by the report, a resident was scheduled for a dermatology appointment. Not only was the resident's family not informed of this appointment, the resident herself was never picked up to attend the appointment. The patient was not told why the appointment was missed.

In most, if not all cases, an individual is placed in a nursing home because he or she no longer has the full ability to care for him or herself. In such cases, it is a necessity to maintain open and clear lines of communication both internally within the facility and externally to family members or legal guardians. Failure to do so is unacceptable, and can lead to dire consequences for the most vulnerable member of the equation: the patient.

The entire DOH report can be found here.