Oklahoma Nursing Home Resident Death Contributed To By "Tightly Tucked Covers"
Heatheridge Assisted Living Center, a Tulsa nursing home facility, has been cited by the State of Oklahoma for twelve violations following a June 2008 investigation. These violations, among other things, include providing inadequate medical care to residents and failure to have a registered nurse supervise and oversee licensed practical nurses and direct care personnel. The report from state Health Department investigators indicates that the facility did not coordinate for health care services with third-party providers, such as hospice nurses, causing actual harm to several residents. The facility has been flagged for "immediate and serious concern".
One resident contracted methicillin-resisant staphylococcus aureas, or MRSA, in her urine and urinary catheter during a March 2008 hospitalization. Her physician ordered daily dressing changes and evaulation of pressure ulcers on lower limbs. In an amazing situation of the right hand not knowing what the left hand was doing, a hospice nurse told investigators that Heatheridge staff was providing care for the staph-infected areas. A licensed practical nurse for the facility advised that "I don't do skin assessments. Hospice does them." The resident was admitted to the hospital on June 11 suffering from dehydration, malnourishment, and sepsis, as well as multiple pressure sores. She died on June 12.
The state report advised that the resident had been improperly restrained with "tightly tucked covers resulting in pressure ulcers to the lower extremities". Several wounds on the resident's right leg were also infected with staph at the time of her death.
The state asked the facility's registered nurse how she supervised the LPNs and other staff to ensure that residents were properly cared for. She responded, "I'm only the consultant. I'm not really her overseer or her supervisor. I don't consider myself in charge." It was also determined that she was only at the facility two days a week, in direct violation of federal laws governing nursing home facilities.
