Illinois Nursing Home Fails To Learn From Its Own Errors After Patients Continually Develop Pressure Sores

elderly in bedIt seems like I frequently receive bursts of telephone calls from clients regarding problems at certain nursing homes.

Sure, it could simply be a coincidence that these folks decided to give a call about problems at the facility– at roughly the same time– but a closer evaluation of the circumstances typically reveals that many of the similar complaints are indeed related to significant care-related problems at the facility.

Particularly when it comes to the development of pressure sores (also know as: pressure ulcers, decubitus ulcers or bed sores) I commonly preach that these horrific emblems of neglect are the result of a broken system of care at the facility. Make no mistake about it, pressure sores result when shift-after-shift of nursing home workers fails to attend to the needs of patients day-after-day.

Frankly, another disgusting example of this systemic neglect was reported in a recent article appearing the article “Alton nursing home faced sanctions.”  The article details how Eunice C. Smith Nursing Home almost lost it Medicare funding after several nursing home surveys confirmed inadequate care that resulted in the development of pressure sores on numerous patients.

Interviews conducted with staff and review of patients’ medical charts portray a facility that not only ignores the care requirements of patients, but a lack of communication when it comes to conveying important medical information to families.

For example staff at Eunice C. Smith never notified a patient’s son (and legal representative) that his father was receiving medical treatment for an early-stage pressure sore over the course of several weeks. It wasn’t until the the patient was admitted to a local hospital did the son become aware of the wound (by which time the wound had become advanced).

Not surprisingly evidence of improper care was not confined to the above situation, surveys from the facility document patients with existing pressure sores left unattended by staff for hours on end— when the patients were incontinent!  Further, the survey identified patients who developed pressure sores within weeks of their initial admission to the facility.

Oh, but no need to worry according to administrator Harold Lutz, while referring to the survey findings, “[t]he scope of it was not very widespread.”  Similarly deflecting the significance of the findings, “[i]ndustry-wide, things like this do happen from time to time.”

Obviously, Mr. Lutz doesn’t have a family member at his facility.

For more information on nursing homes in Chicago look here. For laws related to Illinois nursing homes, look here.


Why do nursing homes describe pressure sores according to ‘stages’?

Is sepsis related to bed sores?

What information should a facility document in individuals with bed sores?

What legal action can be taken if a bed sore developed during an admission to a long-term care facility?


3 responses to “Illinois Nursing Home Fails To Learn From Its Own Errors After Patients Continually Develop Pressure Sores”

  1. onewhocares says:

    Pressure sores are not limited to residents in Nursing Homes. I am a nurse who worked in Assisted Living untl I couldn’t deal with the substandard care anymore and left. A lot of these residents, especially those who are in Alzheimer’s/Memory Care units are incontinent. This can lead to problems if they are not kept clean. If you have a loved one in a facility like this check them out – do it yourself to see there are no sores. You probably won’t be told -Assisted Living doesn’t have the same regs are nursing homes. I have seen new residents get pressure sores a week after they were admitted because they were not kept clean. CHECK FOR YOURSELF and DO IT FREQUENTLY. Take photos if you find sores, document as things unfold. These Assisted Living places should NOT take Alzheimer’s/Memory care patients – they are not qualified by any means to handle this population.

  2. Jennifer B says:

    My grandmother is in a care home – LTC, she developed a reddish mark on her lower back, a few days later it was, as they told me, black in color, than a few more days later they said that it was emitting an odor. They were cleaning and dressing it and turning her every 4 hours. My mother and I had a meeting with the staff and they told us that it was a Kennedy Terminal Ulcer. My friend who is a nurse, told me I needed to get a second opinion…because KTU show up quick and the patient will die within 24 hours. My grandmother is still alive a week later and in a lot of pain. I have done research only to find that it is a Decubitus Ulcer and is treatable. My grandmother is incontinent, has a UTI, doesn’t eat much of the home food, cause she doesn’t like it, however if we bring home cooked food (like she is used to) she will eat that. There is only 1 Patient Care Technician on the floor that is calling it a pressure sore. They are now turning her every 2-3 hours. They are giving her a pain med every 6 hours, but in between the time the meds kick in, she has endured A LOT of pin. In between the prescribed pain med and the next time it is administered, if she feels pain (which she does) they will give her tylenol. Hospice is involved as of yesterday. So which is it?

  3. Jennifer-
    I truly am sorry to hear about your grandmother’s condition. Like all aspects of medicine there is a great deal of debate concerning a condition that you referred to as a Kennedy Terminal Ulcer. The term was coined by nurse Karen Kennedy after she reportedly identified a distinctive shape and color of pressure sores on patients who died shortly thereafter.
    While the term has been embraced by some in the healthcare community as proof that the development of pressure sores on some patients is an inevitable part of the aging process— there is a substantial body of evidence to the contrary.
    Rather, the conditions identified by nurse Kennedy have not been consistently replicated in a medical environment. As you note, a substantial number of these specialized Kennedy Ulcers are nothing more than ordinary pressure sores— which indeed are usually the result of inadequate care. As you can describe, despite the fact that this nursing home identified the wound as having unique properties there seems to be evidence that it is no different than any other pressure sore.
    Best regards,

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