Once a loved one is admitted into a nursing home, assisted living center or rehabilitation facility, the administrator, nursing director and intake staff often assure family members that the resident will be provided much-needed attention, assistance and care. Sadly though, our Cicero elder abuse attorneys have seen a significant rise in the number of occasions where residents acquire a preventable pressure sore (decubitus ulcer; pressure ulcer; bedsore) within days or weeks after their arrival.
If your loved one developed a bed sore during an admission to a Cicero, IL nursing home, contact the Nursing Home Law Center today for a free case review with an experienced attorney. All consultations are free and no fee is charged unless we are successful on your behalf.
Facility-acquired bedsores are not recognized as typical medical conditions by most medical professionals. This is because there are only a few exceptional reasons why the development of a bedsore is entirely unavoidable. In nearly all cases where the aging, disabled or paralyzed resident who requires partial or full assistance to move or readjust their body can avoid developing bedsores when the nursing staff provides routine “turns and repositioning” every hour or so.
Nursing home residents that are permanently or temporarily bedridden/wheelchair-bound must move from side to side at least once every two hours. This repositioning relieves pressure on specific areas of the body that have a higher propensity to develop a bedsore when continuous pressure is not relieved. Typically, these major areas include shoulder blades, shoulders, heels, ankles, sacrum and hip bones. If the pressure is not relieved, the restricted flow of blood to the area can cause tissue and skin to quickly die, creating a bedsore that has the potential of becoming an open wound susceptible to infection.
The Cicero nursing home neglect attorneys at Nursing Home Law Center LLC recognize the majority of cases involving pressure ulcers are the result of neglect. In many cases, there is no acceptable reason that pressure sores occur. Typically, there is not adequate staffing or the staff on hand has not been properly trained to identify and follow protocols to ensure that a newly developed reddened areas on the body do not become open infected wounds.
Our elder abuse network of attorneys routinely gathers information from national nursing home databases including the federal portal Medicare.gov. The sites publish filed complaints, opened investigations and health concerns in nursing facilities all throughout Illinois. Many families take this information into consideration before placing a loved one in a skilled nursing facility.
Our Cook County nursing home neglect attorneys have posted our findings and primary concerns, outlining the nursing facilities below that currently maintain a well below average one star out of five possible star rating. Many of these nursing homes have serious problems involving the level of care they provide the resident’s in treating existing and facility-acquired pressure sores.
6120 West Ogden
Cicero, IL 60804
(708) 863-0500
A “For-Profit” 237-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
In a summary statement of deficiencies dated 03/04/2015, a complaint investigation was opened against the facility for its failure to “immediately assess, identify and treat a sacral pressure ulcer in a timely manner.” The deficient practice affected one resident at the facility who was “reviewed for pressure ulcers.”
The initial nursing assessment of the resident on the date in question “includes a skin assessment with no documentation of skin breakdown noted to sacrum. [The resident’s] progress note dated 01/18/2015 indicates redness to both buttocks was observed.” However, the progress report conducted for the resident on 01/18/2015 “does not contain documentation of notification to [the resident’s] physician or family.” Follow-up progress notes for the resident dated 01/25/2015 indicate that the resident “was observed with irritation, redness and open skin located between his buttocks [… and that the resident] received barrier cream with a plan to follow up with treatment nurse.” However, the resident’s progress notes do not indicate that the physician of the family of the resident was notified of a change in the resident’s skin condition.
The 01/26/2015 progress notes for the resident do indicate that the resident’s physician “was called with a message, left for orders related to the [resident’s] sacrum wound.” However, no notification to the resident’s family of the resident’s change in condition is documented in those progress notes.
Our Cicero nursing home neglect attorneys recognize that any failure to follow protocols concerning a change in a resident’s condition could place their health and well-being in jeopardy. Failing to notify the resident’s physician of a degrading pressure ulcer might be considered negligence or mistreatment because it does not follow established procedures adopted by Alden Town Manor Rehabilitation and Health Care Center.
7733 West Grand Avenue
Elmwood Park, Il 60707
(708) 452-9200
A “For-Profit” 245-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
In a summary statement of deficiencies dated 04/23/2015, a complaint investigation was opened against the facility for its failure to “reposition residents every two hours and ensure a pressure relief mattress does not have multiple layers for prevention or treatment interventions for pressure ulcer.” This deficient practice affected three residents at the facility “reviewed for pressure ulcers.”
The opened investigation was initiated in part after observation of three residents lying on their back in their beds. “The residents were observed with special mattresses. [The mattresses of two residents were] covered with a fitted sheet, folded flat sheet and an incontinence (cloth) pad. [Another resident’s] mattress was covered with a fitted sheet and an incontinence (cloth) pad.”
In addition, the state surveyor noted during the observation that the “turning clock” – a device used to ensure residents are being turned or repositioned at least every two hours – indicated that “the residents should have been on their left side lying position during the observation instead of lying on their backs.”
Two facility Wound Nurses were present during the observation. When asked, both Wound Nurses “stated that the special mattresses should be covered with a flat sheet only to obtain the pressure-relief as recommended by the manufacturer and according to their policy. Both [Wound Nurses] stated the nursing assistants were already told about it but the nursing assistants keep doing the wrong practice. Both [Wound Nurses] also confirmed all the resident should have been positioned on their left sides at the time of the observation [instead of lying on their backs].”
During an interview with the facility’s Director of Nursing, it was revealed that “the facility protocol is to turn residents at least two hours.”
Our Cicero nursing home lawyers recognize that any failure to follow protocols, policies and procedures in regards to bedsores could jeopardize the health and well-being of the resident and might be considered negligence. In addition, the deficient practices by the Wound Nurses, CNAs and Director of Nursing do not follow the established policies adopted by Elmwood Care and violate state and federal nursing home regulations.
1000 114th St
Whiting, In 46394
(219) 659-2770
A “For-Profit” 80-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
In a summary statement of deficiencies dated 02/18/2015, a complaint investigation against the facility was opened for its:
This deficient practice directly affected one cognitively impaired resident at the facility who was “sent to the hospital emergency room [… and] was then admitted to the hospital” on 02/08/2015.
The resident’s 12/23/2014 Minimum Data Set (MDS) quarterly assessment indicated “the resident’s cognitive patterns were severely impaired. The assessment also indicated that the resident required extensive assistance of two staff members for bed mobility, transfers and personal hygiene [… and] required extensive assistance [when involved in activity, requiring staff provide weight-bearing support] of one member for dressing [… and] the resident was at risk for the development of pressure ulcers and had no current pressure ulcers.”
A review of the February 2015 physician’s orders indicates there are no “other treatments to any open areas, pressure ulcers or blisters to the heels obtain between 02/01/2015 and 02/08/2015.” A review of the February 2015 Nursing Progress Notes under the 02/07/2015 entries indicate “there was no documentation of the development of any blisters or pressure ulcers to the resident’s left heel.” On the morning that the resident was sent to the hospital “there was no documentation of the development of any blisters or pressure ulcers to the resident’s left heel” on the Nursing Progress Notes.
However, a review of the February 2015 hospital records indicates that an RN [registered nurse] in the emergency room noted at 8:30 PM on 02/08/2015 that “the resident arrived to the hospital emergency room from a nursing home. The resident’s temperature was 102.4 any skin was hot to touch. An unstageable (a wound with full thickness tissue loss in which the base of the ulcer was covered by slough and/or eschar in the ulcer bed) wound to the left heel was noted with eschar (thick leathery necrotic or devitalized tissue, frequently brown or black in color) present.”
The state surveyor interviewed the facility’s Administrator on 02/17/2015 who revealed “she [the Administrator] was first made aware that the resident had a bedsore to the left heel on 02/09/2015 [the day after the resident had been admitted to the hospital] when the family voiced concerns about the heel pressure ulcer to her.” In a follow-up interview the next day the Administrator also stated that the nursing staff “should have assessed the ulcer, notified the physician and family, completed an ulcer assessment form and documented all of the above in the resident’s record.” The Administrator also indicated “there was no weekly skin check after 01/30/2015 and the 01/30/2015 skin check sheet should have been signed by the nurse also.”
Our Cicero/Whiting nursing home neglect attorneys recognize that any failure to follow protocols, policies and procedures concerning pressure sores could place the health and well-being of the resident in immediate danger requiring hospitalization. These deficient practices might be considered mistreatment or negligence because they do not follow established protocols adopted by Hammond – Whiting Care Center and violates state and federal nursing home regulations.
8540 South Harlem
Bridgeview, Il 60455
(708) 598-2605
A “For-Profit” 404-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
In a summary statement of deficiencies dated 05/21/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure physician’s orders were followed.” The deficient practice directly affected one resident at the facility who “currently has three open wounds: A right trochanter surgical wound [… and] right ischium Stage IV pressure ulcer, first discovered on 02/29/2012, currently measuring 3.0cm x 1.0cm x 0.7cm, which contains red, beefy tissue, exposed muscle and serious drainage.” The resident also has a “left ischium Stage III pressure ulcer, first discovered 05/07/2015, currently measuring 2.8 cm x 2.4 cm x 0.3 cm. This ulcer wound bed is described as red, beefy with 10% slough tissue and serosanguinous drainage.”
The Wound Care Coordinator for the facility indicated that “this ulcer was an unavoidable, facility-acquired ulceration (despite the presence of an air mattress) caused by [the resident’s] friction and shearing and she is able to move her body from the waist up.” However, an interview with the resident on 05/18/2015 at 11:00 AM indicated that “no one changed me [referring to incontinence brief) since 6:00 AM, since the night shift. I am paralyzed from the waist down, but the doctor taught me to feel my pads with my hand to see if I am wet. I am not being checked or changed every two hours like they are supposed to do. I have put my call light on to let them know, but still no one is coming to change me. Also dressing on my sores have not been changed since Saturday (05/16/2015).”
The state surveyor conducted a 05/20/2015 interview with the facility’s Director of Nursing who indicated that “incontinent resident should be checked for incontinence at least every two hours and as needed. It is important for the incontinent resident with wounds to have his/her skin kept clean and dry from urine, which can cause maceration and irritation. Wound dressings should be applied per physician’s/nurse practitioner’s orders. If a dressing becomes loose, soiled or is missing, the nurse needs to replace it.”
Our Cicero/Bridgeview elder abuse attorneys recognize the deficient practices at the facility might be considered negligence or mistreatment of residents because nursing staff, directors and administrators are not ensuring that the staff is following protocols and policies including the facility policy titled Treatment and Prevention of Skin Breakdown. The policy reads in part:
“Incontinence products will be changed after each incontinence episodes and upon a.m. (morning) and hs (bedtime) care. Peri-care will be provided after each incontinence episode.”
In addition, our Illinois nursing home neglect attorneys recognize these failures could jeopardize the health and well-being of the resident because nursing staff did not follow the resident’s 05/07/2015 care plan that reads in part “wound dressing/treatments need to be intact to promote skin healing and prevent infection” [… and] “includes the following interventions good Peri-care and drying of skin. Reposition resident frequently when in bed, chair specialty, chair and/or wheelchair.” The Director of Nursing indicated that “incontinence is a big issue. Urine coming in contact with wounds prevents healing. Incontinent resident needs wet briefs to be changed promptly. It is also important to perform wound treatments as ordered and to keep wound dressings dry and intact to promote healing.”
315 North La Grange Road
La Grange Park, Il 60526
(708) 482-6668
A “Not-For-Profit” 86-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
In a summary statement of deficiencies dated 02/06/2015, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “assess, identify and treat a facility acquired pressure ulcer.” This deficient practice directly affected one resident at the facility with “a history of diabetes mellitus and impaired mobility.” The resident’s admission MDS (Minimum Daily Set) “states that the resident as at risk for pressure ulcers has impaired cognitive skills, needs assistance with ADLs (activities for daily living) and uses a walker [… and] also has three identified risk factors from the facility pressure ulcer policy.”
A review of the resident’s records and clinical notes reveal a 01/24/2015 document that the resident “as a result stage III wound on right heel. On 01/23/2015 [the facility’s wound care nurse] documents in physician’s notes to discontinue current treatment to write heal, discontinue bunny boots (protective heel boots) and low air loss mattress.” However, a 01/27/2015 1:50 PM observation of the resident’s right heel with the facility’s acting wound care nurse revealed the resident has a “bottom right heel had a tan colored scab with reddened skin around the scab. Resident had on socks with no protective boot and no air loss mattress. [The resident said] ‘ouch’ when the sock was removed [but] denied need for pain medication. [The acting wound care nurse] stated that she had never seen the wound before today because [another wound care nurse] had charted the wound as resolved [… and] also stated the pressure sore was not resolved and measured approximately 0.4 centimeters.”
An interview with the attending physician on 02/06/2015 at 10 AM revealed that the attending physician “had not seen the pressure ulcer in about three weeks. At that time the wound had a scab and was dry. [The previous wound care nurse had] called with wound assessments and per telephone [the attending physician] would give orders for [the resident]. [The attending physician] stated he was not informed the wound was resolved and did not discontinue treatment, protective boot or low air loss mattress for [the resident].”
Our Cicero/La Grange nursing home neglect attorneys recognize that any failure to follow physician’s orders and established protocols adopted by the nursing facility could place the health and well-being of the resident an Immediate Jeopardy. The deficient practices might be considered negligence or mistreatment especially if a bedsore is allowed to degrade due to a lack of necessary care.
6631 Milwaukee Avenue
Niles, Il 60714
(847) 647-7444
A “For-Profit” 300-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
In a summary statement of deficiencies dated 10/29/2015, a complaint investigation was opened against the facility for its failure to “correctly administer a resident’s treatment orders, demonstrate a resident’s wound treatment was administered and have a device in place or implement another method to off load pressure on the resident’s heel.” This deficient practice directly involved one resident at the facility with the facility “acquired unstageable pressure ulcer to the left lateral heal.”
A review of the resident’s POS (physician’s orders) dated 10/9/2015 revealed treatment to include “right heel: clean with NSS (normal saline solution), pat dry and apply phone dressing once daily. On 10/14/2015 orders were changed to add Santyl ointment to the right heel once daily.”
However, a review of the resident’s TAR (Treatment Administration Record) indicate that no entries were documented or treatments administered to the right heel on 10/10/2015 through 10/13/2015 or to the left heel on 10/10/2015 through 10/12/2015 and again on 10/25/2015 and 10/26/2015.
The state surveyor conducted an interview with the facility’s wound care nurse on 10/27/2015 where it was revealed the nurse “administered treatments to [the resident’s] wounds and applied a foam dressing to the left heel. [The resident’s] left heel treatment orders were discussed post application.” The wound care nurse stated “so, maybe I consider the foam a dry dressing.” The state surveyor asked the wound care nurse if the physician’s orders were followed. The nurse replied “I guess not. No, I know not.” The state surveyor noted that before the dressing change, the resident’s “calves were positioned on two pillows (in bed), her left heel was lying on the bed.” The facility’s Director of Nursing stated during an interview that the resident’s heels were “not floating heels and they have been in-serviced.”
Our Cicero/Niles elder abuse attorneys recognize that failing to follow established procedures and protocols adopted by the nursing facility concerning bedsores could harm the health and well-being of the resident. In addition, it violates federal and state laws and does not follow Regency Rehabilitation Center’s own policy titled: Managing Tissue Load that reads in part:
“It is the policy of this facility to manage tissue load and improve tissue tolerance to pressure, friction, and shearing forces. This will be accomplished through the use of appropriate positioning practices, positioning devices, and support devices. Providing Local Wound Care: It is the policy of this facility to treat the wound according to current standards of clinical practice.”
2901 South Wolf Road
Westchester, Il 60154
(708) 531-1441
A “For-Profit” 120-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
Primary Concerns –
In a summary statement of deficiencies dated 03/11/2015, a complaint investigation against the facility was opened for its failure to “assess, monitor, document and provide pressure sore treatment to residents as ordered.” This deficient practice directly affected a resident who is “moderately impaired with cognition and would require total assistance with transfers, toilet use and bathing.”
The resident’s records reviewed that the resident “is non-ambulatory and would require extensive assistance [with] two or more person physical assist with hygiene and bed mobility.” The Initial 05/14/2014 and 08/12/2014 Braden Scale assessments on the resident indicates the resident “has a mild risk for developing pressure ulcer.” However, the 11/12/2014 Braden scale indicated that the resident now had a “moderate risk of developing pressure ulcer” and by 01/30/2015 had risen to a “high risk of developing pressure sore.”
The resident’s weekly pressure ulcer record indicated that on 12/09/2014, “the resident developed a stage II pressure ulcer on the coccyx area measuring 0.5 centimeters by 0.3 centimeters by 0.1 centimeters” with “scanty amount of serosanguinous exudate. The wound bed was pink & white in color and had maceration surrounding the skin.” The report also indicated “this coccyx ulcer [recurred] after history of healed pressure ulcer.” The physician provided orders including daily treatments until they were discontinued on 01/26/2015.
In addition, the resident developed an unstageable left gluteal fold pressure ulcer, which was first noted in with the coccyx pressure ulcer in the 12/09/2014 report, measuring 2.0 centimeters by 2.0 centimeters. However, by 02/24/2015 the unstageable pressure ulcer had increased in size to 3.0 centimeters by 3.0 centimeters “with a foul odor.” The resident’s physician provided treatment orders. However, a review of the resident’s records “showed no treatment administration record the documented treatment application as ordered to the left gluteal area from 12/19/2014 through 01/01/2015 (order changed on 01/02/2015).”
The state surveyor conducted a 03/11/2015 3:50 PM interview with the facility’s Director of Nursing who stated “we have looked high and low we cannot find the TAR for the resident. [The Director] was referring to the Treatment Administration Record for the 12/19/2014 through 01/01/2015 left gluteal order.” A 03/11/2015 4:25 PM interview of the former primary physician revealed “that she was the [resident’s] physician until 01/26/2015.” The doctor indicated “she gave treatment orders for [the resident’s] sacral area on 01/20/2015 and for the left gluteal fold on 12/19/2015 [… and] stated that when she ordered the treatment on the [resident’s] sacral area daily, it should be done daily [… and] also stated that if the staff provided treatment to the resident, it should be documented in the medical records because that is the only way to know that the treatment was provided as ordered.”
Our Cicero/Westchester elder abuse lawyers recognize any failure to follow doctor’s orders in treating a bedsore could cause significant additional harm and injury to the resident. The deficient practice might be considered negligence or mistreatment because it violates state and federal nursing home regulations and does not follow the facility’s August 2012 practice guides regarding skin management that reads in part:
“Residents admitted with skin impairments will have wound location and characteristic documented in the nursing notes. In addition, the pressure ulcer – weekly pressure ulcer record will be completed.… Pressure ulcers are measured in stage weekly in accordance with the Practice Guidelines.”
If a nursing facility provides adequate training to their nursing staff, many facility-acquired bedsores could be prevented. However, this requires the staff be trained to assist residents when moving in repositioning and learn the effective protocols and procedures to properly treat the sore. Any failure along the way to take adequate steps to improve an existing bedsore or prevent one from occurring might be considered negligence. Typical action that must be taken by the staff to avoid bedsores include:
Reposition the resident bound to a wheelchair at least one time every 15 minutes
Turn or move any individual confined to their bed at least one time every two hours;
Angle the bed ridden resident to ensure they never lie on their hip bones;
Assess the Resident’s Skin each day – typically during shower time – and use proper and effective skin lotion that minimizes the potential of skin breakdown;
Provide Low-Pressure Mattresses constructed to reduce most body pressure to avoid restricting blood flow to the area of skin and underlying tissue;
Provide the Adequate Nutrition and Hydration because malnutrition and dehydration can increase the potential of developing pressure sores;
Manage Incontinence to ensure that the skin remains dry and bacteria-free; and
Incorporate Exercises into the resident’s daily routine whenever possible to ensure that the resident remains as mobile as possible.
The nursing staff including Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistant must remain diligent in inspecting the resident’s skin, assessing any noticeable change, identify any potential bedsore and informing the resident’s doctor to develop an effective care plan for treatment. Any failure to do so could be considered mistreatment or negligence of the nursing staff, attending physician, Director of Nursing and Administrator of the facility.
It is crucial the family member advocate on behalf of their loved one while residing in a nursing facility to ensure that their health and well-being are protected. Many times, families will hire personal injury attorney who specializes in nursing home abuse cases. A skilled attorney working on behalf of the family and victim can provide numerous legal options to win justice and obtain financial compensation for the victim.
If you suspect your loved one shows the signs or symptoms of mistreatment or neglect that results in a nursing facility-acquired bedsore, it is essential to take quick action. The Cicero nursing home abuse attorneys at Nursing Home Law Center LLC have represented many victims of nursing home abuse including those that of acquired a life-threatening bedsore in an Illinois nursing facility. Our team of knowledgeable lawyers can put an end to the unacceptable level of care provided to your weak and vulnerable loved one.
We urge you to contact our Cook County elder abuse law office today at (800) 926-7565 to schedule your free, no obligation full case review. All information you share with our network of attorneys remains confidential. We accept all wrongful death lawsuits, personal injury claims and nursing home neglect cases through contingency fee agreements. This means we provide you, your loved one and family members legal representation without an upfront fee. Our office is uniquely situated to assist you with your pressure sore case as we have helped many families in your situation. Learn more about our case results here or for an in-depth discussion of pressure sore case valuation in Illinois look here.
Should you have questions about Illinois law related to pressure sores, view our page here.
For information on bed sores and nursing home negligence in other Illinois cities, please review the pages below:
Attorney Jonathan Rosenfeld
Licensed in Illinois
Chicago Lawyer Nursing Home Law Center LLC Home