Bronx Nursing Home Fails to Create Proper Care Plan to Prevent Pressure Ulcers

A July inspection by the Department of Health at St. Patrick’s Home, a Bronx nursing home, revealed that the facility had failed to create a proper plan of care for a resident at risk for the development of pressure ulcers. The resident was a ninety-three year old woman, who upon admission to the nursing home displayed several risk factors for developing pressure ulcers, including an already present Stage II ulcer of the right ankle.

After the resident’s admission, several notes document the presence of the ankle ulcer. These include evaluations and reports from the physician, physical therapist, and wound care physician. Each note includes some form of description of the sore. In an interview with the DOH, the LPN who initiated the resident’s “Impaired Skin Integrity Care Planning and Progress Report” reported that the care plan was not fully created or implemented because, at admission, the woman’s wound was not open. When asked for comment, the Director of Nursing stated that regardless of the sore being closed, a skin integrity sheet should have been started, with weekly follow-ups to monitor for possible further skin breakdown.

According to the DON, and St. Patrick’s own Skin Integrity Risk Assessment and Skin Care Policy, any time that the staff observes a skin issue a skin integrity sheet is to be implemented to track progress or deterioration of any skin impairment. The purpose of such a sheet is not only to monitor the wound, but also to document preventative and rehabilitative procedures taken by the staff. Without the sheet being implemented, tracking of an effective treatment program would be difficult for the nursing home to maintain.

Development and deterioration of pressure sores in elderly nursing home residents can lead to serious consequences, up to and including infection and death. Because of these grave risks, it is incumbent upon a facility to implement a proper plan of care to deal with residents who are at risk for skin breakdown. Based upon the Department of Health inspection last summer, St. Patrick’s Home did not provide this necessary service for at least one of its residents.

The full report, including safety and food preparation deficiencies, can be accessed on the Department of Health website here.

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