Commander Nursing Center Fails to Provide Appropriate Care for Pressure Ulcers

Commander Nursing Center was cited after “the facility failed to identify and failed to follow physician orders for pressure ulcer [care].” The facility failed two different residents by:

– Not identifying one resident’s pressure ulcer until it was a Stage 3;
– Not following physician’s orders to treat another resident’s wounds.

In the first incident, medical records document that the resident had no skin concerns listed for weeks. However, the next documentation showed that the resident had a stage 3 bed sore to their lower hip bone area that had never been previously documented. A Stage 3 Classification is serious and does not develop out of no where. A Stage 3 Pressure sore is a wound that extends through the second layer of skin into the fatty tissue beneath. Bone, tendon and muscles are not visible yet, but if not cared for correctly will become visible as the wound transitions into a Stage 4.

Stages of pressure ulcers/bed sores are classified by stages 1, 2, 3, and 4. The area where the bed sore appeared should have been noted in earlier stages before and cared for before reaching Stage 3 classification. Since it was not, it appears that the facility was not checking the resident for skin conditions until this Stage 3 ulcer formed. During an interview with a Registered Nurse (RN), it was confirmed that the wound should have been identified much earlier. The RN has no explanation as to why the wound was not identified until it was considered a Stage 3.

In the second incident, the facility failed to follow physician treatment orders and facility policy concerning a resident’s bed sore. The physician treatment orders were “to apply skin prep to left heel twice daily and off load heels with [heel pressure relief] boots as tolerated.” Off loading boots are specialized boots that prevent the resident’s body weight from inflicting shear force to the bottom of the foot so wounds heal faster. The facility policy titled “Pressure Ulcer Prevention Guidelines” revealed under the section “Preventative Skin Care,” staff should inspect the resident’s skin while providing care, paying close attention to bony prominence.

The facility investigation revealed multiple staff members did not follow these care/policy orders.
After not providing treatment as ordered, a Licensed Practical Nurse (LPN) said “they were not a wound care nurse and had replaced the dressing with what they had removed from the resident’s left heel.” They admitted they should have reviewed the physician orders before providing treatment.

A second LPN also did not follow care orders because there were no green boots available. This LPN applied skin prep to the wound area but instead of offloading heels with the [heel pressure relief] boots, they applied an Allevyn dressing to protect the area. The LPN stated skin prep was applied to the area but since there was no green boots, they applied an Allevyn dressing to protect the area instead. “They further stated they had meant to go back and chart the findings and write a new order until the boots were available but had become distracted by aiding other residents.”

Pressure ulcers are very painful and can become very serious wounds if not monitored and cared for correctly. Signs of a pressure ulcer should be recorded well before a wound reaches Stage 3 classification. In the case of this facility, failing to do so indicates neglect. In the same way, it is imperative staff follow care orders set in place by physicians so pressure sores don’t progress or become infected.

Commander Nursing Center has been cited previously and discussed in a number of our earlier legal blog posts. The facility has been cited for the abuse of a resident in relation to toileting needs, for multiple cases of mishandling instances of abuse, and has been noted as a Special Focus Facility in South Carolina.

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