Sepsis Infection from Pressure Ulcers Blamed for Death of New York Nursing Home Resident

Sepsis Infection from Pressure Ulcers Blamed for Death of
New York Nursing Home Resident

Failure to provide the care needed to prevent and heal residents’ pressure ulcers points to a systemic provision of sub-standard quality care and may result in the submission of false claims

Compliance Perspective – Pressure Ulcers

Policies/Procedures: The Compliance and Ethics Officer with the Director of Nursing and Administrator will review the policies and procedures involving the provision of care and prevention of pressure ulcers for all residents admitted to the nursing home.

Training: The Compliance and Ethics Officer with the Director of Nursing will ensure that staff are trained to provide the care needed for all residents, including regular re-positioning for pressure relief, adequate supplies, and appropriate equipment for residents with limited mobility to prevent pressure ulcers.

Audit: The Compliance and Ethics Officer should personally conduct an audit to determine if staff are following policies and procedures for providing pressure relief and care for residents, and if each resident has the appropriate equipment and supplies.

Four months after an 82-year-old man was admitted to a New York nursing home for rehabilitation after a stroke, he was sent to the emergency room and was found to have seven pressure ulcers on the lower part of his body. He died 14 days later from cardiac arrest caused by a sepsis infection.

The son of the resident blames the nursing home for the resident’s death, and he reported that hospital emergency room doctors and nurses told him that the pressure ulcers on his father were the worst they had ever seen.

The nursing home received citations from New York State Health Department inspectors three times from 2015 through 2018 for its failure to provide proper treatment and prevention of pressure ulcers to other residents. The citations included conditions that inspectors observed at the nursing home two days after the resident was transferred to the hospital.

The nursing home is reported by the Centers for Medicare & Medicaid Services (CMS) to have had the worst record for residents with pressure ulcers among 47 nursing homes in the surrounding area in 2017. Pressure ulcers in 2018 seem to have gotten worse for the nursing home’s long-term, high-risk residents.

A spokesperson for the nursing home attributed the high percentage of pressure ulcers in the nursing home to the nursing home’s admitting a greater number of obese residents. He noted that 12 of the facility’s 85 residents are bariatric patients and their care is complicated due to the need for specialized equipment, beds, and chairs.