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The LPN also stated that she thought the wound had gotten better with this treatment and that it had not hurt the resident.




PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.



Complaint # (AR 599) was substantiated (all or in part) in these findings.
A. Based on record review and interview, the facility failed to ensure a disinfectant for equipment and non-porous hard medical surfaces was not used as a wound cleanser for 1 (Resident #4) of 6 (Residents #3, #4, #16, #19, #31, and #32) case mix residents who had pressure ulcers. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #4 and had the potential to cause more than minimal harm for 7 residents who had pressure ulcers as documented on a list provided by the Administrator on 11/6/14 at 11:45 a.m. On 11/6/14 at 4:40 a.m., the Administrator was informed of the Immediate Jeopardy. The findings are:

On 11/6/14 at 4:10 a.m., Licensed Practical Nurse (LPN) #1 performed wound care to the Resident’s left heel and left lower leg. The LPN stated that the resident had gone to the wound clinic Monday and had measurements there. She also stated, the wound on the lower leg is larger but looks healthier. The wound on the heel is larger and worse. At 4:30 a.m. after completion of the wound, the LPN was asked if she was aware of anyone using something on a wound that was not to be used on wounds. LPN #1 stated, I did. I wouldn’t ever mean any harm to a resident. I used this. (The LPN showed the surveyor a spray bottle of Clorox Brand Hydrogen Peroxide Cleaner Disinfectant for hard surfaces and equipment). The LPN continued, (Resident #4) won’t let anyone but me and (LPN #2), another LPN that works nights, change his dressing. We were gone about 6 days and his dressing had not been changed for the 6 days. I was trying to find something that would help his wounds. They were draining yellow drainage and looked awful. So, I started using that. The LPN was asked if she was aware the cleaner was not for wounds. She stated, yes, but it does not have bleach in it. The LPN was asked if she had gotten physician orders [REDACTED]. The LPN also stated that she thought the wound had gotten better with this treatment and that it had not hurt the resident. She was asked how long she used it on the resident and she stated, about 2 weeks (10/6/14 – 10/20/14). She stated that the last time she used it on the resident was the day the resident went to the hospital (10/20/14) and had not used it on any other residents. The LPN was asked if anyone else was aware of her use of the cleaner on Resident #4. She stated, yes, the Treatment Nurse.

Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

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25 Responses to “The LPN also stated that she thought the wound had gotten better with this treatment and that it had not hurt the resident.”

  1. Mary says:

    I don’t believe my mom is abused as much as emotionly not supported. Everyone in nursing homes has different needs and support I wish nursing home workers would put themselves in the residents place and not treat them so coldly

    • Teresa says:

      I am a nursing assistant who works in a long term care facility (aka nursing home). I have worked in this field for nine years. I take pride in my job, and I try to treat each resident as a member of my family. I have formed close connections to my residents and care for them. I’m sorry you feel the staff is “cold”. Sometimes, as healthcare workers, we put our feelings aside, especially when dealing with families. There are a lot of times we are emotional that we don’t let anyone else see. I have cried and grieved over a resident who has passed. And I sobbed as I gave a resident a final bedbath, in preparation for the funeral home to arrive. I have shared a resident’s goal when he/she regains the ability to walk again, or is able to go home. Not all healthcare workers are cold and unfeeling. I love what I do, and I love taking care of people.

      • daughter says:

        It is good you care but there are health care assistants who don’t that give the goods ones a bad name. My dad was in a long term care facility and got good care some weeks and horrible care some weeks and no one would listen not even the admin.

        • Nursinglpn says:

          I agree that families need to be there more often but dont come into a facility once a year complaining that uour loved ones aren’t being taken care of.

    • Lynda says:

      I am a CNA and work in a facility. I love all my residents and give them emotional support. But what family members need to also understand is that we have between 10-15 other patients that we are responsible for and sometimes cant spend the time that the resident or the family thinks we should. We work long hours sometimes not eating or drinking or even taking a bathroom break. We are the ones that wake them up, clean them up, feed them, put them to bed and in a lot of cases are then ones holding their hands when they are scared and lonely. We are often the ones that are holding their hands when they take their last breath.

      • Kathy says:

        I agree with you, Lynda. I’m an STNA. Too many residents, not enough staff. You want to take time with each person, and they do appreciate it when you stop and just talk to them. Then, your nurse tells you to stop visiting and get back to work! There’s just not enough time.

        • judith oehring says:

          There needs to be legislation by the gov. to hold big companies to a ratio to severity of illness not number of patients per aides – aides are hard working individuals who are poorly compensated and given too many patients to take care of the way they deserve to be taken care of and what they pay for

      • Kim says:

        Totally agree! I was only on a 2 day clinical rotation at a nursing home and was sickened that these patients couldn’t get the care they deserve. CNA’S are overworked and underpaid. They don’t have time to take care of patients like they want to. There are too many patients and very little help.

    • Kris, RN,BSN and soon MSN-FNP says:

      Hi Mary, treat the residents coldly?
      Let’s explore this, shall we??

      If by “treating them coldly” you mean giving them care, feeding them, being their only visitors for weeks, and sometimes months, on end..then yes, I suppose you are right.

      But lets look at the fact of how many families put grandma/grandpa in a LTC facility and pretty much forget about them until it comes time for their loved one to pass…then out of the guilt the family feels for not being there, the staff is the punching bag.

      I have seen this so many times, and it is pathetic.

      I am not saying what this LPN did was right, but there are two sides to every story….
      So when you say “cold” know that the staff is sometimes the only family the residents have.

  2. Faye says:

    What the LPN did with the wound was wrong. The product had never been tested in that area and could cause long acting results.
    But what you say about LTC workers is not correct. Many nurses and techs consider the residents of the facilities as their second family. I have worked in long term care for most of my 42 years as a nurse. I have been a nursing assistant, LPN and finally an RN. I have held just about every position there is in a “nursing home”, including DON. Most of us love our residents and would do just about anything for them. We are not cold. We are caring and loving.

  3. Cindy says:

    Thank you Lynda Teresa and Faye for your devotion to your residents

  4. C Haugland says:

    I worked in long term care for many years. Most of the workers are there because we truly love and care for our residents. We have to because for the most part it is the only thing keeping us there. I started as a CNA 35 yrs ago and have been an LPN for 31yrs. That being said fast food workers want to make $2 less than me and 1.5x what the average PCA or CNA makes! What our who is more important?

  5. Criss-Ann Pendleton says:

    The fact the LPN used a product not for wound care (as my mind blows) whatever in God’s green earth possessed her to think it was ok to us it. It’s actions like that which gives LPN a bad name.
    I too have worked LTC most of my 26 years 5 as a CNA,21 as an LPN. I love my job and my residents. To some residents we are all the family they have which is sad. Education is so badly needed. Wound care in services are needed. Hope the patient was alright

  6. Phyllis Haley says:

    I am an LPN and worked the first 20 years of my career in a Long Term Care facility. You have to love the elderly. You know right away if that job is for you. I loved my patients and did all I could to make life special in “their home”. It takes a special person for that job. They are like your family. I work for a Hospice agency now and this is very rewarding some days and heartbreaking other days.

  7. Ken says:

    Yes it was a bad idea to use product made for cleaning hard surfaces in the treatment of anything pertaining to human treatment, she/he made a poor judgement call. There are solutions out there for wounds that have bleach in them, 10% Dakin’s is a common astringent odor eliminating solution that is effective on some wounds. However taking any form of treatment into your own hands as a nurse, RN, LPN, or LVN is stepping outside scope of practice and most nurses know this… sounds like the above nurse is either too new to realize the mistake, or has been a nurse too long and gotten too comfortable making calls independently. I hope the resident recovers well, and I don’t agree that all care givers in LTC or rehab units are calloused or not caring. I’ve been in all fields of nursing and I’ve seen a lot, but after losing my grandparents, I found my home in LTC providing care to the elderly and severely disabled. For me, I may have lost 4, but everyday when I clock in, I gain 90 grandma’s and grandpa’s!!!

  8. Melissa James, RN says:

    Bottom line, the nurse had a duty to follow physicians orders and did not do so. She should be reprimanded accordingly. I hope the patient’s wound improves and the nurse and staff learn a valuable lesson. Nurses are human too and just because they make an error does not mean that they don’t care!

  9. Danita says:

    I also have worked in LTC for 20 years most of them as either a CNA or CMA. I do this job because I love what I do. My residents are family to me and I am family to them. My daughter comes in as a volunteer and visits with them and she loves it also. I look for her to follow in my footsteps when she is old enough and I will be very proud if she does. I went back to school and got a Pharmacy Tech degree but just couldn’t give up my job in LTC I love it to much.

  10. bobbie says:

    I have worked in health care all of my adult life. I get very attached to the residents, clients, patients. I try to trest them as family and as I would want to be treated. It is a hsrd job, stressful job and can be very hsrd watching those people die. I have (do) work in a favility where the people have no family so at times, we as staff are all they got. What that nurse did was totally wrong but not all health care workers are “cold””

  11. Alicia says:

    CNA for 15 yrs in long term car. And loved my residents like family. We are often closer to them than the families are and know them at their present state better than family. Most sides take good care out them and would do anything to make the last months or years of their lives the best possible. We don’t make anything and often working short staffed. Or overtime sometimes almost every day or double shifts.with No respect or appreciation. Harassed by bosses And families and not to mention beat on physically Most of the time. Just for trying to do our job the best anybody could. Yes there’s bad aides. Just like there are bad people in general but if we viewed all people as bad people the way we lable CNAS Nurses etc… Then this world would be coming to a end… Love my job… Haven’t become a nurse for that reason alone. I have great pride in what I do and it is a calling… Even if pay sucks… That smile on the residents face makes the low pay tolerable.

  12. Carla Bushey says:

    WOW What is wrong with her? I am stunned anyone would even think it was ok to use BLEACH on a wound… I have been a LPN for over 20 years..She is insane doing this a cold hearted person.

  13. I work in Social Services and am often pulled to work on the floor. I feel sad every day I work because there is NEVER enough time; no time to visit, to hold hands, to read to residents. Families expect us to be everything for their loved one. Many of our residents can’t do anything for themselves; we feed them, dress them, turn pages for them when they’re looking at music, set them on the toilet, clean them afterwards, oftentimes change their clothes again, lay them down to nap, reposition them every 2 hours, and then it all starts over again. CNA work is the most difficult work I have ever done, both emotionally and physically. I wouldn’t do anything else; the love I have for our residents is palpable. There are people who abuse residents, but I don’t work with any of them The people in our facility are loving, caring, tired & overworked. The lack of help is turning into a real problem for many nursing homes. Families need to realize this when they come barging in and yell at CNAs because, “My mom isn’t ready to go and I called two hours ago and you guys never get her ready on time.” They don’t understand that 2 hours ago we HAD their mom ready, but then she had an episode of incontinence and we had to change her entire outfit. This took 3 people & we only had 4 on the floor to begin with. It’s very difficult.

  14. Terry says:

    I work in LTC. And believe me most nurses and techs dread the family’s more then the residents. Not all families are horrific but the ones that are greedy, fake and expect us to give the care they should be giving and know is impossible to give, ( they couldn’t do) are the ones that cry abuse and neglect. Most bed sores happen d/t a decrease in nutrition, not because we aren’t feeding them but they have declined and the appetite is one of the 1st to go and lack of fluids because they stopped drinking not that we stopped giving them drinks. And the skin is the last organ the body cares about when the brain heart and other major organs need the calories so break down will happen. And just because they are soiled when u came in doesn’t mean they have been sitting in it all day, most times they just got changed. Having FAMILIES stop feeding, fluids but don’t sit at BS while they seizure, cry out are the same that cry abuse and neglect. Like someone else just stated its usually money and or guilt. And falls, wow my favorite , families are shocked, angry and cry abuse or neglect, when they know if at home they are NOT staying up all night to watch them and toilet them and they would fall multiple times if it were just them caring for mom or dad. We have them cause you don’t want to take the time they took raising you all their lives, wasting it on them now. I have sat and held hands while the last breath taken, while abuse and neglect is being thrown around. Not all families are like this but way to many then should be. Nursing homes are easy lawsuits to so many, they think. It’s gross. I have gone 12 hours without bathroom breaks, meals, and seeing my family taking care, GOOD care of yours. I have seen and worked with lazy nurses and “stupid” ones too but trust me the good clean places don’t keep those kind around and get weeded out fast. Can’t even imagine what this nurse was thinking, but don’t think she ment real harm. If you could give the care you expect us to give they wouldn’t be with us.

  15. Rhonda says:

    For over 18 years I have worked with resident’s in LTC (long term care/nursing homes)and many other nursing fields, both as a nurse and as a wound specialist. Many nurses don’t have enough knowledge regarding wound care yet they perform those duties every day, and it is much more than putting a dressing on a wound. Many nurses are thrown into a wound care position without proper education, then products (bleach, vinegar, soap), like in this State survey situation are used in wounds. For any nurse that has used Dakin’s solution (that is just about any nurse that has done wound care), you have used bleach in a wound in a dilution ratio that is cytotoxic, being 1/2 strength, unless you have a physician that knows the dilution ratio of Dakin’s (0.025%). But I can tell you that this bleach solution is used ALL the time by physicians. All I can say is education, education, education! a great need for all nurses in these facilities, if the nurse is educated then this can ultimately help the resident’s, and if you are a nurse and you think you don’t need education, especially in wound care because that is not your job, you are wrong. Every nurse can learn something, knowledge can be powerful.

    As far as the resident’s and the care provided in these LTC facilities (I have been in many LTC facilities), the staff often have a strong connection to these resident’s and are like their family, most of them rarely have a visiting family member. In some instances facilities have issues with being understaffed, so the care giver can’t spend as much time as they would like to with each resident they care for, and it often seems hurried. Each facility is different and every staff member is different, as we are dealing with humans. Families need to be more involved as this would help them understand what it is like to cloth twice a day (or more), bath daily, feed 3 times a day (or more), toilet every 2-3 hours, reposition every 1-2 hours, take to activities or therapy, provide medications, do any necessary treatments, and much more in a 24 hour period for 100+ people… then they would understand without complaining so much about what was not done in a timely manner, this is no easy task for anyone.

  16. Jan says:

    I am in no way condoning putting a cleaning solution on any facility resident. It can be so difficult for family members to understand that care facilities are not substitutes for homes, and care staff are not substitutes for families and friends. Visiting your loved one(s) every day, eating with them, doing their laundry, and being there for them continues even though they are no longer at home. The staff does so much for your loved ones, but, as was expressed above, must move on to the many folks waiting for their professional attention. They are not cold individuals, believe me. So move your loved one to the closest facility to your home and go there every day yourself or set up a schedule so that someone in the family goes every day – even teenagers. You’ll be doing so much good.


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