In October of last year, the New York State Department of Health conducted a certification survey at Ocean Promenade Nursing Center, a nursing home in the Rockaway Park section of Queens. The report notes that this was a repeat deficiency for Ocean Promenade, meaning that the facility had been cited for a similar violation in the past.
The resident, a seventy-two year old, was admitted to the facility with two existing Stage II pressure ulcers (bedsores), each located on the sacrum (lower back/buttocks). Upon admission, the Nursing Progress Note documented that the resident had multiple open skin areas on and around the sacrum. A care plan was initiated, detailing several interventions, including topical cream application and wound care rounds. Although the wound care intervention was put into place on the resident’s admittance care plan, the wound team did not see or evaluate the pressure ulcer until two weeks after admission. At this point, the resident had developed a decubitus ulcer on the sacrum measuring (in centimeters) 15 x 15 x 0.2. At admission the sacral ulcers measured 0.5 x 0.5.
In reading the DOH report, it appears that miscommunication could be a source of issues regarding pressure ulcers at Rockaway Park. In interviews conducted after the DOH assessment, the RN stated that it is the duty of the admitting RN to notify the wound care team of the pressure ulcer in order for the team to monitor and treat the sore. She also stated that initially the wound was not a pressure ulcer, but that due to incontinence it had progressed into one. Whether in response to this statement by the RN or as a stand-alone comment, the admitting nurse claimed that she had, in fact, alerted the wound care team to the need for ulcer monitoring. In any event, the team did not assess the resident until two weeks had passed post-admission. By this point the pressure ulcer had deteriorated into a much more serious state.
Failure to properly treat pressure ulcers was not the only deficiency documented by the Department of Health in its October report. For a complete synopsis of the findings, including failure to develop comprehensive care plans and failure to prevent catheterization unless unavoidable, visit the Department’s website here.