The New York State Department of Health (DOH) fined the Teresian House Nursing Home, a 302-bed facility located in Albany, New York, $25,350 in November 2013 for failing to treat a patient’s open wound that developed into gangrene. The affected resident was originally diagnosed with a thyroid disorder, high blood pressure, osteoporosis and peripheral vascular disease, a medical condition that makes patients susceptible to pressure sores. The resident’s care plan stated that staff members needed to assess the patient’s skin every shift.
On October 6, 2013, a licensed practical nurse (LPN) noticed that the resident had an open wound between the toes of the left foot. The LPN also noticed that the resident had a large bruise on the same foot. The LPN then notified the nursing supervisor about the patient’s open wound. According to the nursing home’s policy titled “Pressure Ulcer–Prevention & Care Planning,” nursing supervisors are required to assess a patient who is reported as having an open wound. In addition, the nursing supervisor must notify the physician and create a “skin tracker” document to be placed in the patient’s medical chart. However, after being told of the patient’s wound, the supervisor failed to follow the facility’s policy.
On October 18, 2013, twelve days after the resident’s wound was discovered, a staff member noticed that the patient’s left foot was red and foul smelling. The patient also had a fever. Staff members notified a physician, who ordered that the patient be transferred to the hospital, where the resident was diagnosed and treated for gangrene. An LPN stated that staff members failed to perform daily skin checks as required by the patient’s care plan.
DOH investigators looking into the matter concluded that “The facility was unable to provide documentation that the resident’s left foot was being monitored, assessed, or treated; or that the physician had been notified of the left foot.” The DOH also cited the facility for failing to report the incident to them as a possible case of neglect.
As a result of the survey, health inspectors also discovered that a dementia patient had eloped from the building. According to a DOH report, the patient was assessed as an elopement risk and was required to wear a Wanderguard, an electronic monitoring device that sounds an alarm if the patient exits the facility. On September 26, 2013, the resident was found by some visitors outside the facility. Although he was brought back into the building, his Wanderguard never went off. Per the nursing home’s policy titled “Elopement Management Program,” staff members must report cases of elopement within five days of an incident. However, an administrator told a DOH inspector that she did not report the incident because the resident never left the grounds of the nursing home.