Articles Posted in Pressure Sores

Highland Care Center received 31 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 10, 2020. The Jamaica nursing home’s citations resulted from a total of three surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate (bedsore) pressure ulcer care. Section 483.25 of the Federal Code requires nursing homes to ensure that residents receive “care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable.” A May 2019 citation found that Highland Care Center did not ensure a resident with a pressure ulcer received adequate care. An inspector specifically found that the resident’s pressure-relieving device for their foot/leg ulcer was “missing” and “not in place.” A Certified Nursing Aide stated in an interview that the resident’s heel booties had been sent to the laundry and should have been returned the following day, but when she checked the laundry they weren’t there; “she did not report this to her nurse,” the citation states. A plan of correction undertaken by the facility included nursing staff in-service education and the provision of new heel booties to the resident.

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Resort Nursing Home received 30 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 9, 2020. The facility was also the subject of a 2010 fine of $2,000, in connection to findings of health code violations related to nutrition. The Arverne nursing home’s citations resulted from a total of four inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not provide adequate care to promote the healing of pressure sores (bedsores). Section 483.25 of the Federal Code stipulates that home facilities must provide residents with adequate treatment and services to promote the healing of pressure ulcers and bedsores. According to a November 2015 citation, Resort Nursing Home did not provide one resident with necessary treatment for such. The citation states specifically that the resident was provided with “incorrect treatment to his right heel.” The resident had five ulcers, according to the citation, and an inspector observed a wound nurse provide treatment to one of them in a manner that was not in accordance with the physician’s orders. The citation notes that this deficiency had the “potential to cause more than minimal harm,” and the facility noted that it potentially affected all residents with pressure ulcers.

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The Pavilion at Queens received 11 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 12, 2019. The Flushing nursing home’s citations resulted from a total of four inspections by state authorities. The violations they describe include the following:

1. The facility did not ensure the professional care and services of residents’ pressure ulcers. Section 483.25 of the Federal Code requires nursing homes to provide residents with “care that is consistent with professional standards of practice” to promote the healing of pressure injuries / ulcers. A May 2018 citation found that The Pavilion at Queens failed to comply with this section in connection to one resident’s care. An inspector specifically found that a nurse employed improper technique when tending to a resident’s wound dressing, using one hand to peel off the dressing instead of two hands, and touching gauze to the mouth of a saline bottle—which the citation states could risk infection transmission—rather than pouring the saline out of the bottle onto the gauze. The citation states that this deficiency had the “Potential to cause more than minimal harm.”

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Park Terrace Care Center received 30 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 19, 2019. The facility was also the subject of a 2017 fine of $2,000 in connection to findings in a December 2016 survey that it did not provide adequate pressure ulcer care. The Rego Park nursing home’s citations resulted from a total of four inspections by state authorities. The deficiencies they describe include the following:

1. The nursing home did not provide adequate treatment and services for residents’ pressure ulcers and bedsores. Section 483.2 of the Federal Code requires nursing homes to residents persons who enter without pressure sores from developing them unless their condition renders such unavoidable; and that residents with pressure sores receive treatment and services adequate to promote their healing. A December 2016 citation found that Park Terrace Care Center did not properly assess and evaluate a resident who was admitted to the facility “with intact skin and a discoloration” on their left foot. The resident subsequently developed an “unstageable pressure ulcer,” according to the citation, which goes on to state that whereas the resident’s plan of care provided for the wearing of a left air boot “at all times after the pressure ulcer was identified,” this provision was not followed by staff. The citation states that this deficiency in the facility’s treatment and care resulted in “actual harm” to the resident.

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Queens Boulevard Extended Care received 16 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 19, 2019. The Woodside nursing home’s citations resulted from a total of three inspections by state authorities. The deficiencies they describe include the following:

1. The nursing home did not provide adequate treatment and services to promote the prevention and healing of pressure ulcers and bedsores. Section 483.25(c) of the Federal Code stipulates that nursing home facilities must provide treatment and services to promote the healing of pressure injuries / ulcers, and to ensure that residents admitted without pressure ulcers do not develop them unless medically unavoidable. An August 2019 citation found that Queens Boulevard Extended Care did not provide a resident with a level of treatment and services consistent with professional standards to promote the healing of their ulcers. An inspector specifically found that the facility did not implement the use of pressure relieving devices for a resident who had bilateral heel wounds. The inspector observed a Registered Nurse performing wound care treatment to both of the resident’s feet, but without putting pressure relieving devices in place after completing the wound care. A review of care records did not find any “documented evidence for the application of the use of heel protectors while in bed,” although facility policy provided for the use of pressure relief assistive devices in instances when pressure relief was warranted.

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DRY Harbor Nursing Home received 25 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 19, 2019. The Maspeth nursing home’s citations resulted from a total of three inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not ensure necessary treatment and care of bedsores / pressure ulcers. Section 483.25 of the Federal Code requires nursing homes to ensure that residents with pressure ulcers receive “necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.” A January 2019 citation found that one of DRY Harbor Nursing Home’s Licensed Practical Nurses “did not practice acceptable standards and wound care techniques” for a resident suffering from a stage 3 pressure injury. Among other findings, an inspector observed the LPN removing the resident’s diaper and rubbing the wound site with gauze after running saline over the wound, contravening the best practice of patting areas dry to prevent tissue damage. The inspector also observed the LPN applying “two parallel strip amounts” of medical creams a gauze strip, instead of mixing the creams together. According to the citation, the LPN then put the same diaper back on the resident, later informing the inspector that “using a clean diaper would have been referable in keeping with infection control practices.”

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The Emerald Peek Rehabilitation and Nursing Center received 31 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 26, 2019. The Peekskill nursing home’s citations resulted from a total of three inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing did not provide treatment and services of a degree adequate to ensure prevention and/or healing of pressure ulcers. Section 483.25 of the Federal Code requires nursing home facilities to offer residents “care, consistent with professional standards of practice, to prevent pressure ulcers” from developing and to heal existing pressure ulcers. A January 2019 citation found “no evidence” that when a resident developed a pressure ulcer, the facility undertook actions to get rid of risk factors connected to pressure ulcer development. In response to the citation, the facility implemented a plan of correction that included weekly risk assessment and intervention audits to ensure the proper execution of preventative measures for pressure ulcer development.

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Hamilton Park Nursing and Rehabilitation Center received 9 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 22, 2019. The Brooklyn nursing home’s citations resulted from a total of two inspections by state surveyors, in November 2016 and May 2018. The deficiencies they describe include the following:

1. The nursing home did not take adequate steps to care for prevent pressure ulcers and bedsores. Under Section 483.25(c) of the Federal Code, nursing homes must provide a level of care that prevents residents who enter without pressure sores from developing them unless their condition renders such unavoidable; and that residents suffering from pressure sores must receive necessary and adequate care. A November 2016 citation describes the failure by Hamilton Park Nursing & Rehabilitation Center to follow orders to provide a resident with “dry protective dressing on a sacral ulcer.” The resident was admitted to the facility with three unhealed pressure ulcers, according to the citation, and a physician ordered that one of them be treated in part with dry protective dressing. An inspector observed the resident without the required dressing, and spoke to a staff nurse, who “confirmed that she was not informed that the necessary dressing was missing and needed to be replaced.” The inspector determined in an interview with a Certified Nursing Assistant that the CNA had forgotten to inform the nurse of such.

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Bedford Center for Nursing and Rehabilitation received 36 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 22, 2019. It also received a Department of Health fine of $6,000, in September 2011, over alleged violations of sections of the health code relating to the investigation and reporting of allegations, accidents and supervision, and administrative practices. The Brooklyn nursing home’s citations resulted from a total of four inspections by state surveyors. The deficiencies they describe include the following:

1. The facility did not provide an adequate level of treatment and services to prevent and heal pressure ulcers. Section 483.25 of the Federal Code states that nursing homes must provide residents with “care, consistent with professional standards of practice, to prevent pressure ulcers.” A November 2018 citation found that Bedford Center for Nursing and Rehabilitation failed to ensure that a resident received adequate care to prevent pressure ulcers. An inspector specifically observed on multiple instances that the resident was in their bed without wearing heel booties. According to the citation, the resident was at “very high risk” for skin breakdown, and medical orders directed that heel booties be applied while the resident is in bed. In interviews, both a Registered Nurse and a Licensed Practical Nurse stated that they were not certain why the resident was not wearing the necessary assistive devices while in bed.

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Beth Abraham Center for Rehabilitation and Nursing received 30 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 14, 2019. The Bronx nursing home’s citations resulted from a total of five inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not properly ensure the prevention and control of infection. Under Section 483.80 of the Federal Code, nursing home facilities “must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” During a May 2019 inspection, a surveyor observed a Licensed Practical Nurse “performing blood pressure monitoring for 3 residents without cleaning the blood pressure cuff between residents”; another LPN administering eye drop medication without maintaining “proper hand hygiene”; and a third LPN failing to maintain proper hand hygiene while completing a wound care observation.

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