Westchester Nursing Home Fails to Prevent Development of Bedsores

In a citation dated May of this year, the Department of Health listed Cedar Manor Nursing and Rehabilitation Center (a Westchester County nursing home) as deficient in several areas of care. Among these was a failure to provide proper treatment to prevent or heal bedsores (pressure sores, decubitus ulcers).

The resident reviewed by the DOH was an eighty-one year old man admitted to the facility with several underlying conditions, including being post-tracheostomy tube insertion and post-gastrostomy tube insertion. The man also suffered from several risk factors for pressure ulcers, such as dermatitis, incontinence, skin that was often moist, and limited ability to change position. He was totally dependent upon the staff for most day to day activities. An assessment also listed the resident as nutritionally deficient. Despite the presence of these numerous risk factors, the care plan for the resident was not updated with additional interventions to address them.

About two weeks after admission, an observation of the patient showed that he had several open wounds on and around his lower back. By the next morning, three of the wounds had merged into one Stage II pressure ulcer. The other two wounds, upon the second examination, were unstageable pressure ulcers. Based upon the multitude of risk factors that the resident displayed, the nursing home had a duty to update his care plan accordingly, providing interventions to address these needs. When warning signs such as these go unheeded, the risk of developing one or multiple pressure ulcers is heightened. For the resident profiled at Cedar Manor, this risk became a reality. The DOH report provided no update on the man’s current condition.

The Department of Health report can be accessed here.

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