Resort Home, a skilled nursing facility in Queens, New York was found to be the worst in Queens County at preventing and/or healing pressure sores (bedsores, decubiti) in residents at “high risk” for pressure sores. Federal and State investigators found that 35% of residents deemed as “high risk” for pressure sores, had developed pressure sores. The New York State average is 13%.
In a specific instance detailed in the December 15, 2008 inspection, the dietician at the Queens nursing home failed to properly address a resident’s nutritional needs once a pressure sore had developed. There was no documented evidence that the resident’s nutritional needs were assessed in order to address the deterioration of the pressure ulcer. As a result, the pressure sore progressed from Stage II to Stage IV in a matter of days.
In the same investigation, it was determined that a nurse’s aid attempted to transfer a resident on her own as opposed to transferring the resident with the assistance of another aid (when the care plan specifically called for a two-person transfer), resulting in a fall.