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Vancouver, WA – Nursing Home Fails to Identify and Treat Pressure Sore; Gets Caught Trying to Blame Hospital


Located: 1015 North Garrison Road, Vancouver WA 98664 was recently cited in November of 2013 by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following:

Please Note: The following highlighted quotes are only a portion of the full report. The full and complete report can be found here.

Based on interview and record review the facility failed to ensure 1 of 4 sampled residents (#1) at risk for developing pressure ulcers, or having a pressure ulcer received timely treatment to promote wound healing. The facility failed to identify resident #1’s pressure ulcer, notify the physican and provide appropriate necessary treatment. This failure resulted in actual harm to the resident as the pressure ulcer worsened requiring hospitalization and specialty services of a wound clinic. There was no evidence the facility recognized the pressure ulcer and there were no orders written for treatment.


Weekly skin assessments between 9/10/13 and 10/15/13 indicated there were no skin issues. Progress note written night shift 10/11/13 stated, Patient had skin wounds on/near coccyx area. There was no doctors’order found or any indication in the documentation to indicate the physician was made aware of the wounds. There was no documentation to support there was any assessment of the wounds completed. Progress note written 10/11/13 dayshift stated, .buttocks and coccyx area red and excoriated; cleaned and protective cream applied. Again there was no mention of wounds or assessment being done or physician notified of any change in condition.


When the facility assessed the resident prior to sending her to the emergency room they documented on the skin grid – pressure ulcer/[MEDICAL CONDITION] ulcer/other form, the pressure ulcer on her coccyx was unstageable and was 9cm x 8cm and pressure ulcer to the right anterior coccyx was unstageable and 11cm x 7cm. On 10/30/13 the family, according to the progress notes, insisted the resident be sent to the emergency room for treatment of [REDACTED]. Resident was taken to the emergency room and returned to the facility on [DATE]. Facility stated in their investigation, the pressure sore was present on admission to the facility. There was no evidence found in the documentation to indicate they were aware of the pressure ulcer prior to 10/30/13. There was no treatment or assessment completed of a pressure ulcer prior to 10/30/13. Resident did have care plan in place with interventions such as air flow mattress and turning every 1 or 2 hours but no other treatment or interventions were noted. In an interview with resident #1 on 11/19/13 she stated she did not have a pressure ulcer when admitted to the facility. She stated she did not always get turned and when the pressure ulcer developed staff did not do anything about it.


In an interview with the director of nurses on 11/19/13 she had no explanation as to why staff had not identified the presence of the pressure ulcer but believed it had developed in the hospital and was present according to hospital documentation when resident returned to the facility on [DATE]. She agreed the assessment of slight redness was not the same as a stage III pressure ulcer. She agreed the lack of assessment and appropriate treatment led to the worsening of the residents’ pressure ulcer. She stated she had/was implementing interventions to prevent future episodes.

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.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Share your story with us, spread the word and HELP STOP THE ABUSE AND NEGLECT! Stop the companies who hire inadequate and poorly trained staff in order to gain profits from our helpless elderly.

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One Response to “Vancouver, WA – Nursing Home Fails to Identify and Treat Pressure Sore; Gets Caught Trying to Blame Hospital”

  1. Cindy Jencks says:

    I am a retired registered nurse that worked in nursing homes for 17 yrs. I am only 52 yrs old and would like to contribute my knowledge to the prevention of abuse and neglect in nursing homes. Do you have any suggestions?


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