Silvercrest, a nursing home in Jamaica, Queens, NY received a deficient rating in a January, 2014 Department of Health Complaint Survey. The deficiency involved the facility’s failure to provide proper and necessary treatment to a resident suffering from a pressure ulcer. The resident had had a previous pressure sore that had healed in December, 2012. Because of this prior wound, and because the resident still possessed several risk factors for the development of pressure sores, Silvercrest had several interventions in place to prevent the development of future ulcers.
Despite these interventions, the female patient developed a new pressure ulcer in September of 2013 on the sacrum, the site of her previous wound. The woman’s treating physician ordered application of bacitracin every twelve hours. When the wound appeared to worsen, the resident’s Nurse Practitioner ordered additional treatments to be administered every shift. Although the new orders were seemingly in place because of the start of deterioration of the ulcer, documentation revealed that the treatment was not administered to the female resident of the course of two days immediately following the new order (a period of six nursing shifts).
Interviews conducted by the DOH with the nurses working these shifts revealed that the new medication was incorrectly ordered, and thus did not arrive in a timely fashion after the institution of the new order. In her interview, the Nurse Practitioner claimed to be unaware of the missing treatment. This contradicted the statements of one of the LPN’s, who told the investigators that she had informed the NP.
As is often the case, it appears that lack of communication contributed to the worsening of this resident’s pressure ulcer. A lack of oversight, or lack of a fail-safe to ensure that orders are followed, does not excuse negligent treatment on the part of the facility. In this case, lack of proper ordering and communication between the Nurse Practitioner and License Practical Nurses allowed the resident’s already compromised physical and mental condition to worsen further. This confusion does not relieve the facility of its duty to provide proper care to its residents, and its duty to follow both state and federal statutes and regulations.
The DOH report did not provide an update on the resident’s current condition.