BRIAR HILL HEALTH CARE RESIDENCE

15950 PIERCE ST, MIDDLEFIELD, OH 44062

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 PROVIDE APPROPRIATE PRESSURE ULCER CARE AND PREVENT NEW ULCERS FROM DEVELOPING.

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

Based on closed record review and interview the facility failed to timely identify the presence of infection to an

completed as ordered to decrease the risk of infection and failed to ensure adequate interventions and monitoring were in place to prevent the development of maggots to Resident #83’s right heel unstageable pressure ulcer. Actual harm occurred on 07/15/18 when Resident #83 was assessed to have increased pain and the presence of maggots in the pressure ulcer requiring hospitalization for debridement and care. This affected one resident (Resident #83) of three residents reviewed for pressure ulcers.

On 08/07/18 at 12:50 P.M. interview with the director of nursing (DON) verified there was no evidence in the medical record that the dressings to the heels were changed daily as ordered on [DATE] or 07/12/18 and no evidence treatment completion was documented on the TAR from 07/10/18 through 07/13/18.

Review of a nursing progress note, dated 07/15/18 at 11:07 P.M. revealed the nurse was called to room of Resident #83. Another nurse was about to change the dressing to the resident’s right heel and noted the ulcer had several small insect-like creatures all over the wound bed, with many going into the sides of wound bed. The perimeter of the wound bed was red and discolored. The physician was notified and ordered to send the resident to the emergency room . The family was notified. The resident was transferred to the hospital at 11:00 P.M. by ambulance and admitted .

Review of the hospital notes, dated 07/15/18 indicated the resident complained of severe pain to her legs, which was likely due to [MEDICAL CONDITION]/wounds. Hospital documentation revealed the wounds were irrigated and a lot of maggots were removed . The notes indicated the resident [MEDICAL CONDITION] (infection) due to [MEDICAL CONDITION] with infected wounds and maggots. The note indicated the resident would need debridement and rule out osteo[DIAGNOSES REDACTED] (bone infection). The hospital history and physical dated 07/15/18 indicated the resident had a chronic ulcer to the bottom of her right heel and she complained of pain. The note indicated staff reported maggots in the wound. The note indicated the resident had a foul smelling sore, the size of a half dollar, to the right heel with visible maggots falling out.

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.

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 have helped many already and we can help you and your loved one as wellby filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.

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