In January of this year, Silvercrest, a Jamaica, Queens nursing home, was cited by the Department of Health for failure to prevent and/or heal pressure ulcers. The survey and the resulting deficiency report involved one resident, a 77 year-old female who was admitted to the nursing home with several diagnoses, among them a sacral pressure sore.
At the time of the incident, the female resident had been admitted to Silvercrest for approximately two and a half years. She had a previously healed pressure ulcer to the same area, the sacrum, at which the subsequent wound developed. After the original sore healed, the facility put in place numerous interventions designed to prevent the development of additional wounds, including pressure relieving mattresses and a turning and positioning program. Despite these proper interventions being in place, a pressure ulcer recurred to the resident’s lower back. An MD assessment noted that the wound was Stage III. After the examination, the physician ordered treatment for the pressure sore during every shift. Treatment was to include cleansing and dressing the ulcer, applying ointment, and securing the dressing.
For the next six shifts immediately following the physician’s order, treatment was not provided to the resident. The Treatment Administration Record listed the reasons for the lack of treatment as “awaiting delivery” and “delivery pending.” During a Department of Health interview with a Licensed Practical Nurse who was on shift for the missing treatments, the LPN stated that the Nurse Practitioner had entered the order incorrectly into the facility computer, causing a delay in the procurement of the medication. Because of poor record keeping, there is no documentation of what, if any, treatment was provided to the patient during the six shifts for which the medication was not available.
New York State nursing homes are governed by both state and federal regulations. These regulations dictate the type of care that nursing home residents must receive. Specific to pressure ulcers, the regulations state that a resident who enters a facility without pressure ulcers must not be allowed to develop pressure ulcers unless his or her clinical condition demonstrates that such development is unavoidable. Additionally, a resident having pressure sores must receive necessary treatment to promote healing, prevent infection, and prevent new sores from developing.
In this case, Silvercrest failed to provide the proper treatment to its resident. Physician’s orders must be followed. Failing to treat a pressure ulcer for six shifts after a physician’s orders is a violation of the resident’s rights, and can have dire consequences. Ideally, this citation by the Department of Health will cause Silvercrest to be more diligent in its future treatment of its residents presenting signs and symptoms of pressure ulcers.