Westchester Nursing Home Cited for Failure to Prevent Pressure Ulcers

Dumont Center for Rehabilitation and Nursing Care, a Westchester Nursing Home located in New Rochelle, was cited by the Department of Health in a September, 2014 deficiency report. Among the numerous failures uncovered by the DOH were failure to prevent the development of pressure ulcers.

The resident was admitted to the nursing home as a known risk for the development of pressure ulcers. Her assessment revealed that she did not have any pressure sores of Stage I or higher. Approximately nine months into her stay at the facility, the resident fell while walking without the use of her walker. After being transferred to the hospital post-fall, it was discovered that she had fractured her hip and needed surgery. Following the surgery and recovery time in the hospital, she was sent back to Dumont.

As she continued recuperation from the surgery, the resident developed a Deep Tissue Injury to her right heel. At the time of its discovery, the sore was unstageable. Although the nursing home had initiated a careplan to prevent pressure ulcers from developing, a review of the CNA Accountability records showed that interventions had been ordered, but not implemented. Only after the sore had developed did the Accountability records show a pillow to elevate the heel and a low air loss mattress. Additionally, an “EZ boot” had been ordered to further off-load pressure, however it did not appear to have been implemented. The DOH made efforts to interview the CNA who had provided care for the resident following her return to the facility after surgery, but the charge nurse LPN could not identify the CNA. In an interview that the DOH was able to conduct, the LPN Rehab and Wound Care nurse told investigators that the nursing home did not even stock the EZ boots that had been recommended by the Wound Care Specialist.

Noted above, upon admission to the facility, the resident was already a risk for the development of pressure ulcers. Her fall and subsequent immobility added to the risk already present due to her underlying hypertension and diabetes. While this added risk factor does make the prevention of pressure ulcer development more difficult, the nursing home is still charged by state and federal regulations to ensure that an individual exhibiting no pressure ulcers does not develop them unless such development is unavoidable. It is impossible to say with any certainty whether the ordered interventions in this case would have worked to prevent such a wound, had they actually been timely implemented.

The full report on Dumont contains details of other deficiencies recorded by the Department of Health during its visit to the nursing home. These deficiencies, including improper labeling of drugs and biologicals and failure to provide services by qualified persons in accordance with a resident’s careplan, can be found here.

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