MANORCARE OF SOUTH HOLLAND

LOCATED: 2145 EAST 170^TH STREET, SOUTH HOLLAND, IL 60473

MANORCARE OF SOUTH HOLLAND was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

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.

FACILITY FAILED TO GIVE RESIDENTS PROPER TREATMENT TO PREVENT NEW BED (PRESSURE) SORES OR HEAL EXISTING BED SORES.

LEVEL OF HARM –ACTUAL HARM

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review the facility failed to utilize a pressure ulcer risk assessment to

individualized interventions for the prevention of pressure ulcers, and failed to provide care and services to prevent the development/or worsening of a pressure ulcer for one of 11 residents (R19) reviewed for pressure ulcers in a sample of 24. These failures resulted in R19 developing a stage 3 pressure ulcer to the coccyx which worsened to an unstageable pressure ulcer.

R19’s Skin Worksheets dated 7/02/15 to 7/13/15 document R19 had redness to the coccyx/buttocks on 7/02/15 which developed into an open area on 7/13/15. R19’s Skin Worksheets dated 7/16/15 to 7/23/16 continue to document open areas to R19’s coccyx/buttock. R19’s wound care progress note dated 7/21/15 and signed by Z1 (Wound Physician) documents Z1 made an initial examination of R19’s new coccyx stage 3 pressure ulcer on that date. The progress note also documents that at the time of Z1’s examination, R19 was wearing a soiled incontinence brief with, .bed sheets soaked with urine, No dressing on coccyx.

On 7/28/15 at 10:35a.m. Z1 (Wound Physician) stated R19’s pressure ulcer to the coccyx was preventable. Z1 stated R19 is totally dependent on staff for turning and repositioning. Z1 stated that despite R19 receiving nourishment through a gastrostomy tube, Z1 did not think poor nutrition was the cause of R19’s pressure ulcer. Z1 proceeded to enter R19’s room for a weekly examination of R19’s pressure ulcer to the coccyx. Z1 pointed to a round wound to R19’s coccyx measuring 2cm (centimeters) x 2.5cm x 0.5cm deep which had a yellow/tan wound bed. Following the examination, Z1 stated R19’s wound had worsened from a stage 3 pressure ulcer to an unstageable pressure ulcer since Z1’s initial examination of the wound 7/21/15. Z1 also pointed to an extensive, irregularly shaped, open area to R19’s left buttocks which had a deep pink wound bed. Z1 stated Z1 was not certain if the open area to R19’s left buttock was caused from incontinence, friction, or pressure. Z1’s wound care progress note dated 7/28/15 documents R19’s, New coccyx stage 3 pressure ulcer appears unstageable now. Etiology pressure, moisture. Increased in size.

R19’s care plan dated 5/13/15 includes interventions to address, Skin alteration at coccyx related to impaired mobility, incontinence, friction. The care plan does not include interventions specific to R19’s stage 3 pressure ulcer to the coccyx. R19’s care plan interventions include, Encourage and assist as needed to turn and reposition. The care plan does not include a turn/reposition schedule.

On 7/28/15 during a continuous observation from 11:00a.m. to 2:00p.m. R19 was lying in bed with R19’s lower body and pressure ulcer flat against the bed. R19 was not repositioned by staff during that time.

On 7/29/15 at 10:10a.m. E2 (Director of Nurses) stated E2 is responsible for verifying the accuracy of residents’ care plans. E2 also verified R19 requires total assistance of staff for activities of daily living. E2 stated R19 has pressure ulcers which requires R19 to be turned/repositioned every two hours by staff. E2 stated E2 was not aware R19’s skin alteration to the coccyx, as was listed on the care plan, was actually a stage 3 pressure ulcer, or that R19’s stage 3 pressure ulcer had worsened to an unstageable pressure ulcer.

Personal Note from NHA-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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