Northern Metropolitan Nursing Home in Monsey, New York was recently cited by the New York State Department of Health for incidents involving residents that developed pressure sores (decubitus ulcers, bedsores) in late 2009. According to the statement of deficiency, inspectors discovered that three out of twenty-one residents surveyed developed pressure sores at the facility. Although the residents were “at risk” for pressure sores, care plans and preventative measures were either not in place, or deficient, in ensuring that the sores did not develop.
One of the residents surveyed was readmitted to Northern Metropolitan on September 2, 2009 with a Stage II pressure ulcer on the sacrum and by December 7, 2009 two more ulcers on the hip and scapula (upper back) had developed. Another resident was readmitted on March 2, 2009 and by August 3, 2009 had developed a Stage IV (the most severe) pressure ulcer on the right Ischium (hip area). In the third case, although a patient was admitted on October 15th, 2009 with noticeably red heels, an individualized care plan was not implemented until November 4th. The resident subsequently developed a Stage II pressure Ulcer. Two of the three patients also experienced significant weight loss.
The actions of Northern Metropolitan are in direct violation of New York Codes, Rule and Regulations, specifically 10 NYCRR 415.12(c). A facility must ensure that all reasonable measures are taken to prevent pressure sores. In the event that a sore is present upon admission or develops despite appropriate measures, a facility must take all reasonable steps to treat existing sores and prevent new ones from developing. Despite the risk factors of these patients, Northern Metropolitan failed to adhere to the standard of care designated by law. This is no doubt a frustrating scenario for both the residents and their families, as with the proper interventions, these sores were, in all likelihood, avoidable.
The facility was also cited for failing to provide services in accordance within accepted parameters of nursing practice.
Website Resource: New York State Department of Health