Westchester County Nursing Home Cited for Failure to Prevent Pressure Sores

The Osborn, a Rye, New York nursing home, was cited in a December, 2013 Department of Health deficiency report for failing to properly treat and/or prevent pressure ulcers. According to the report, the facility did not accurately assess the resident’s condition, and as such failed to institute a proper plan of care to address her propensity for pressure sores.

The resident was 100 years old upon her admission to the nursing home following a hip fracture. She had a pre-existing Stage I pressure ulcer of the right heel, as stated in the Ulcer Flow Sheet at her admission. Despite the presence of the ulcer, the resident’s Minimum Data Set indicated that she had no identifiable pressure sores. The resident had several risk factors for the development of pressure sores, including impaired cognitive skills and requirements for assistance with all activities of daily living. Despite the presence of the sore and these risk factors, no further pressure ulcer assessment was performed.

Less than two weeks into her stay, the resident’s right heel ulcer had deteriorated to a Stage II sore. When interviewed, the RN/MDS assessor stated that the inaccuracy of the initial assessment led to a substandard care plan. Because the patient was improperly assessed, the pressure ulcer was allowed to deteriorate rather than heal. It should be noted that when the resident was discharged, the heel ulcer was in the process of healing.

Accurate care planning is essential for elderly nursing home residents. Intake evaluations to determine a patient’s risk level for the development of pressure ulcers must be performed diligently and accurately to ensure that residents without pressure sores do not develop them, and residents admitted with pressure sores are properly treated. If untreated, a pressure sore, such as the one exhibited by the Osborn resident, can deteriorate, become infected, and potentially lead to death. Fortunately for this resident the sore was eventually treated and seemed to be healing upon her departure from the facility; had the Osborn conducted a proper intake assessment, the sore may not have ever gotten to Stage II.

Contact Information