Somers Manor Nursing Home Cited for Failure to Prevent Pressure Ulcers

A Department of Health certification survey dated December 21, 2012 cites Somers Manor Nursing Home, in Westchester County, for six health inspection deficiencies. Among the deficiencies noted by the Department of Health was failure to properly prevent or heal bedsores (pressure sores, pressure ulcers).

A facility must ensure that residents who enter without pressure ulcers do not develop such ulcers unless it is unavoidable. The DOH report details a seventy year old woman who was admitted with several warning signs for the development of pressure sores. After a partial leg amputation, and the associated diminished mobility, this risk became even greater. As such, the facility implemented a care plan calling for the use of a seat cushion when the resident was out of bed, and also anytime the resident was in a wheelchair. On at least two occasions, the resident was observed out of bed without the assistance of a seat cushion. When interviewed, the Certified Nurse Aide stated that she was not aware of the seat cushion intervention. During the same interview, the same CNA found the seat cushion called for in the care plan. It had been in the resident’s closet.

During examinations of the resident in December of last year, it was discovered that she had developed a stage III pressure ulcer on the sacral area of her lower back, as well as a stage II pressure ulcer on her left buttock. The DOH observed a nurse improperly applying a healing ointment to the area in contravention of accepted practices. The cream was meant to be applied to areas of skin that had healed, yet she applied it to the open, stage II pressure ulcer.

In many cases, the elderly and infirm are powerless on their own to prevent pressure sores from developing. These nursing home residents require the assistance of staff with simple interventions included in the care plans of almost all residents deemed to be at risk for pressure ulcers. These interventions, including turning and positioning, incontinence care, and implementation of seat cushions, cannot be performed by the residents themselves. Unfortunately, as appears to be the case at Somers Manor, at times the nursing home staff fails to follow the protocols laid out for them in these care plans. And, as has been discussed previously on this blog, a pressure sore, once developed, can lead to infection, tremendous pain and suffering, and even death.

Somers Manor was cited for several other deficiencies in the Department of Health survey, including failure to properly establish an infection control program, and failure to keep the facility free of accident hazards. To read about these and the other deficiencies detailed in the December report, visit the Department of Health website here.

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