On January 8, 2013, the Department of Health cited Bishop Henry B. Hucles Episcopal Nursing Home for numerous violations of health regulations. Among these was a violation of Title 42 section 483.25(c) of the Code of Federal Regulations, which deals with prevention and treatment of pressure sores. This section of the Code mandates that the facility must ensure that a resident who enters without pressure sores does not develop pressure sores after admission, unless the resident’s condition makes the development unavoidable.
The DOH report documents a 72 year old female resident who was noted upon admission to be at risk for the development of pressure ulcers. She was admitted with an abdominal wound but no other skin breakdown. Although the facility developed a care plan for the avoidance of pressure ulcers, the Department of Health did not find evidence that proper skin assessments were performed by the staff. Shortly after admission, the resident developed an unstageable pressure ulcer to the sacrum, or lower back. An unstageable pressure ulcer is one for which the depth of the ulcer cannot be determined due to infection, slough, or dead tissue in and around the wound.
As is often the case in incidents involving the development of pressure sores, here the facility’s record keeping is spotty. At times treatments noted in the records are not initialed, preventing reviewers from determining who, if anyone, was providing specific care. Additionally, the resident’s records note that she was non-compliant with preventative care. However the CNA, when interviewed, stated that she could not remember these refusals. She also could not remember specific interventions being applied, such as positioning devices. The LPN stated that the resident actually was compliant with care.
Based upon statements from the Registered Nurse Supervisor, it appears that the facility’s policy for someone non-compliant is to develop an additional care plan to deal with this. It is unclear based on the DOH report if this additional care plan was ever developed. Of course, based on the statements of the CNA and the LPN, it is also unclear whether the resident actually was non-compliant.
Preventing the development of pressure sores is a crucial task for nursing homes and long term care facilities. A great risk of infection and death that accompany such wounds. They also make day to day life extremely painful for residents suffering from them. When a resident who is a known risk enters, the facility must do all within its power to prevent these sores from developing. That does not appear to be the case in this incident at Bishop Hucles.
The DOH report can be read here in its entirety.