Nursing Home Abuse Lawyer Blog

Amberwood Care Center is a 155 bed nursing home facility located in Rockford, Illinois. For the past three years, Amberwood Care Center’s inspection deficiency record has consistently remained poor. Amberwood Care Center received twenty-three deficiencies in 2007, twenty-eight deficiencies in 2006, and fifty-one deficiencies in 2005. The average number of nursing home deficiencies in Illinois is eight. Currently, Amberwood Care Center is rated as a one-star nursing home according to the new system instituted by the Centers for Medicare and Medicaid.

Pressure sores are a well-known risk for bed-bound nursing home residents. Improper treatment of pressure sores, also known as bed sores, can result in severe infection and possibly death. According to the government surveys, Amberwood Care Center placed its residents at risk in this area. A resident exhibited signs of a possible coccyx pressure sore beginning in February 2008. By July 2, 2008, the resident had developed a coccyx pressure sore, which had reached a Stage II status with drainage. On July 10, 2008, a wound care nurse noted that the coccyx pressure ulcer was “unstageable” with a large amount of drainage and 70% thick yellow tissue. On July 16, 2008, the physician notes indicated that a Staph A infection was present in the resident’s wound. Another resident, dependent upon staff for all activities of daily living, had a Stage II pressure sore on her coccyx and Stage IV pressure ulcer. One morning, she was found sitting in her wheelchair, even though she wanted to go back to bed, and was asked if she had a cushion in her wheelchair. She responded, “I don’t have a cushion. It would be nice. I wish I had one.” Later in the day, the resident was seen still sitting in her wheelchair and said, “My butt hurts a little. I have a sore on my butt because they (the facility Certified Nurse Assistants) fool around so much.” The resident was taken to bed and found to have a wet diaper, which can worsen an existing pressure sore and also cause potentially lethal infections. The resident’s Care Plan required repositioning every two hours, incontinent care every two hours, and a pressure relieving cushion when needed. The facility’s own Skin Ulcer Management Protocol policy indicated that residents with Stage II pressure sores on their buttocks, sacrum, or hip were to receive a wheelchair cushion and provide good incontinence care checks every two hours. The nursing staff was in-serviced on pressure ulcer prevention, including using an appropriate wheelchair cushion and reducing pressure off the affected area through repositioning. Staff was in-serviced on proper interventions to control or eliminate friction and shearing forces to a coccyx as well as interventions to prevent infection. The facility’s Director of Nursing was ordered to monitor compliance through random walking rounds to ensure high risk residents were using appropriate wheelchair cushions and being repositioned as needed. To see pictures of the four stages of pressure sores, to go Terry Law Firm, L.L.C.

Nursing home facilities are required to report all alleged violations of abuse, neglect, or mistreatment, whether it be from staff or from another source. During this time period, Amberwood Care Center failed to protect its residents from abuse from other residents. In one instance, a seventy year-old resident became involved in a physical fight with another resident. The resident suffered injuries to his left jaw and had bruising and swelling down his neck. The facility staff had to be in-serviced on the investigation procedure for allegations of abuse, including resident-to-resident altercations and on proper assessment, notification, and documentation of injuries. The facility Safety Committee was instructed to review resident-to-resident altercations at least monthly to ensure procedures were being followed. Staff was in-serviced on completing Behavior Tracking Sheets on residents exhibiting undesirable behaviors. Care Plans are to be reviewed quarterly by the Social Service Director for residents with history of aggressive behaviors to ensure appropriate precautions are in place. Handouts about recognizing warning signs of aggressive behaviors were placed in employee areas for review.

For the safety of all facility residents, certain types of medications, such as Morphine Sulfate, Fentanyl, and Oxycodone, are stored in a double lock container with a key that cannot access any other medications. The facility placed multiple residents in jeopardy when it failed to follow the necessary storage procedures for Schedule II medications. The key locking the Schedule II medication container could also open the discontinued medications storage container.

Care Plans must be in place for each facility resident to meet the resident’s medical, nursing, mental, and social needs and to maintain the highest possible well-being. The facility failed its residents when two residents were involved in a physical altercation at the facility. One resident had not been assessed as being at risk for abuse or for being abusive others and the resident’s Care Plan had not been updated to compensate for the resident’s behavior. Staff was in-serviced on completion of Behavior Tracking Sheets for residents when exhibiting undesirable behaviors. Care Plans were to be reviewed quarterly for residents with history of aggressive behavior to ensure appropriate interventions are in place.

Many nursing home residents rely on facility staff for many, if not all, activities of daily living. Facility staff members are required to provide necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Sadly, residents at Amberwood Care Center did not receiving the treatment they needed or deserved during this time period. One resident’s toenails were yellow, very thick, and long – so long that they actually curled under the edges of his toes. His feet were also dry and cracked. The resident was noted to be noncompliant at times for his personal care, but no one at the facility adjusted the resident’s Care Plan with individualized approaches to address his behavior and needs as required by law. Facility CNAs had to be in-serviced on resident behavior interventions and a facility audit conducted to ensure resident foot care needs were being met.

Certainly accidents are a source of concern at nursing home facilities. While some accidents may not be preventable, most accidents are preventable if the residents are properly supervised. A resident with decreased cognition and awareness began repeatedly falling and suffering from confusion. The resident’s Care Plan was not updated to identify that the resident was a fall risk nor did it provide any fall prevention approaches. Facility staff were instructed to review the resident Safety Assessments to identify other fall-risk residents. An Interdisciplinary Team was instructed to review all accidents and incidents on a regular basis to ensure Care Plans are current and applicable. Nursing staff received in-service instruction for approaches to fall prevention and supervision to prevent accidents.

Keeping nursing home residents involved and active is important for their mental and physical well-being. In at least one instance, Amberwood Care Center failed a resident in this regard. The resident, who has a history of aggressive behavior and was often to be socially isolated, withdrawn, and depressed, was assessed as having leadership abilities, liking to help others, and was interested in volunteering at the facility. Sadly, he was allowed to remain in his room and the facility failed to provide any activities for him. The state ordered the Activities Director to in-service Activity Assistants on offering residents room activities if the resident opts not to attend group activities and to use participation sheets to document attendance at group activities. The Activities Director was instructed to review activity leisure assessments and Care Plans on a quarterly basis to ensure that interventions were in place should residents choose not to participate in group activities.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. For more information, call us directly at 1 (888) 317-2525 or visit our website at www.nursinghomejustice.com.