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Greetings everyone,
My uncle is currently in a nursing home because he had a major stroke in 2019 is paralyzed on the left side, suffers from cognitive impairment and is bedridden. He was recently sent to the hospital because the facility was unable to get his blood glucose under control (478-not being able to get a reading at all because it was so high), a fever of 99, his blood pressure was low and his pulse rate was over 120. After he was admitted to the hospital I found out that he has a stage 4 pressure ulcer on his bottom and surgery is required. He is also recovering from shingles. The nursing home wound care nurse did inform me that he had a pressure ulcer but she told me it was under control and improving. I know he has a lot going on at once but I am having great difficulty understanding how the nursing home allowed it to progress to stage 4 without sending him to the hospital previously, especially since they didn't send him to the hospital because of the pressure ulcer, that was not mentioned as the reason they were sending him to the hospital.

It does not sound like negligence. If he has uncontrolled diabetes then wounds are difficult to heal. He does need frequent turning but do you know if he can respoition himself back on the wound? How long ago was the conversation? Wounds can develop quickly.
Fever, uncontrolled sugar, low blood pressure and high heart rate suggests severe infection or sepsis, which is why he went into the hospital. This can happen very fast so that is why they sent him to the hospital.
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Reply to MACinCT
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Grace21 Apr 19, 2020
MACinCT
He has been in the same nursing home since April 2019 and His blood glucose being uncontrolled is something new. I think the infection from the pressure ulcer is what caused all the other vitals to change. I must also mention his blood glucose has dropped to less than half of what it was since having surgery yesterday and his other vitals are back to normal.
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Grace, your Uncle is still in the hospital, right?
If so please try to find out from the hospital wound care team or the MD who is the hospitalist for his care as to the date he is to likely get discharged. I’d be concerned that his old NH will not accept his back; he will not be able to return. It will be for “not able to provide level of care” reasons. Facilities can and will do this and sometimes the reasons can be quite subjective. Wound care can require specialized treatment.
He is not guaranteed his old bed, doesn’t matter whether he’s private pay or there on Medicare /Medicaid. He has a lot of very complex other issues (paralyzed, bedfast, PEG line) that need speciality care, plus has dementia, and these all notated in his chart before the current wound care issue. And now all these atop Covid-19 concerns. So your filing neglect could just be the cherry atop the not so pretty parfait.

Hopefully old place takes him back with open arms.

BUT If old SNF will not do a readmit, it will fall to the discharge planner at the hospital to try to find a place for him. The usual M.O. is for them to first and foremost lean on family to take them. Like heavily guiltify on family. If that doesn’t pan out, the discharge planner will place calls going out to any SNF who will admit him. Like SNFs in surrounding cities or counties. For discharge planner placement goes to the first facility that will accept the transfer in. There just may not be any choice. If he ends up in the hospital for several days, he will be more than likely discharged for post hospitalization rehab which is a Medicare benefit. The standard is 20/21 days rehab as a patient and then they are discharged from rehab. Facility may or may not accept him as a LTC resident. Then it’s a scramble to find a facility or family takes him home,

You know the facility best. If you think that they were kinda on the fence abt having Uncle continue to live there as a resident, or if there have been care plan meetings in the past and staff has brought up his needing more specialized care and family & DPOA resisted doing this, or if family is viewed as having beyond totally unrealistic expectations for care, then this is an opportunity not have him back.

Filing a formal complaint for neglect to the State is a pretty big deal for a DPOA to do. You are the DPOA, right?

So what do you want to have happen? NH isn’t going to be shut down for 1 resident pressure sore. Unless there’s a verifiable patterns of neglect, at the most it will be a warning or a fine. There won’t imo be lawsuit settlement $ unless he died due to the neglect and left young dependents. Going lawsuit neglect will realistically need a medi-mal attorney that has a MD and RNs on staff or under contract with who will review Uncles charts. Believe me, medi-mal don’t usually ever do contingentcy fee except for class action.
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Grace21 Apr 19, 2020
Igloo thank you for your detailed response it was very helpful. My uncle is still in the hospital, he was admitted on Friday April 17th and had surgery yesterday. Yes I do have DPOA. The nursing home does have prior cases of negligence but a lawsuit is not my main priority, I also know that a lawsuit is time consuming and that is not the avenue I want to take. I just want him to be properly cared for. I don't think that the hospital will convince family members to take him in, he has no children and his siblings are all elderly and I can't imagine them agreeing to take him because of the extensive care he requires, which is why he was discharged to a nursing home in 2019.
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The progression of the pressure ulcer depends on more than repositioning him. The fact that he is on an air mattress means someone either saw the risk of him developing an ulcer or knew he had one.

How is uncle’s nutrition? What is his weight? If he is thin with no subcutaneous fat the pressure ulcer can get worse very quickly. Nutrition is so important. He needs protein to build new tissue. What’s his source of nutrition?

First I suggest you speak with the unit manager and ask her/him what the plan of treatment is for your uncle’s PU. Give them a chance to remedy the situation.

Is your uncle on hospice or palliative care? I say this gently - maybe it’s time to consider that type of care. If his quality of life is not going to improve after surgery (which is probably debridement of the wound or a skin graft using his own tissue to cover the ulcer).

From what you’ve described your uncle must be very ill healing from Shingles too. His immune system is working overtime. It also sounds from his vital signs that he is dehydrated. Due to these conditions he may not be able to fight any new illnesses.

The Formal Complaint Process should be posted somewhere near the lobby. It will outline the chain of notification.

You can report them to the CMS/Medicaid agency on your state level. There should be a process for a surveyor from CMS/Medicaid to go out and audit the facility for very bad infractions.

Good luck!
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Grace21 Apr 19, 2020
Thank you for your response Shane1124. My uncle's source of nutrition is by feeding tube (He has been on a feeding tube since the stroke in April 2019). He weighs approximately 250 pounds. I spoke with the hospital staff this morning and his vital signs are improving since the surgery so I am guessing that the infection was the main source of his vitals being all over the chart. I informed the nurse that my uncle is recovering from shingles and I was told there is no indication that he has shingles because he has been turning him and he sees no sign of shingles (go figure). I was also thinking about seeing if he is eligible for hospice. It is difficult to imagine him in this shape because with Covid19 I can't even see him.
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Each State has a department that inspect facilities.
There is an Ombudsman that will take complaints.
You can also file complaints on the Medicare website. This is a good resource when exploring facilities there is an indication if a facility has complaints and if so of what type.
You do have a right to be outraged about the pressure sore. He should have a mattress that helps prevent them but the staff should be changing his position every 2 hours at a minimum.
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Grace21 Apr 18, 2020
Thank you for your response Grandma 1954. I will check into contacting the ombudsman and look on medicare's website as well. It is funny that you brought up the mattress that helps prevent pressure sores, because he does have a medical air mattress, which leads me to believe that he wasn't being repositioned every 2 hours. As I stated previously I do understand that pressure sores occur especially when someone is bedridden but I just can't wrap my head around why the nursing home allowed it to get so far out of control now he requires surgery because the infection has spread to the bone. I am just so disappointed and disgusted at the lack of care.
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Pressure sores can be so horrific that, unbelievably to laymen, a Stage 4 could be an improvement on what had gone before. It's far from impossible.

There should be excellent documentation, and you should be entitled (with your uncle's authorisation) to see it. Even in the community/domiciliary settings that I work in, if we see anything on a person - bruise, pressure area, cut, rash, *anything* - we complete a body map (I've done two just today). The nursing team looking after your uncle should have either images or hand-drawn body maps charting progress and/or deterioration, and both can happen irrespective of quality of care. It depends on so many things, not least your uncle's compliance from day to day.
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Has your uncle been resident in this NH ever since the stroke in 2019?

You have every right to demand that your uncle's care and treatment are accounted for in detail. Don't jump straight to negligence. What you need is to know what has happened, and you're more likely to get the true, full story if you make enquiries rather than assumptions.

I imagine this will also be true in your state's jurisdiction: that the NH is obliged by law to have a formal complaints procedure and to make it known and accessible to residents and residents' family members and/or representatives. Start there - literally, call the NH's office and ask what the complaints procedure is.
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Grace21 Apr 18, 2020
Country Mouse, yes my uncle has been in the same nursing home since 2019. I appreciate your response. I intentionally called it negligence because I don't think that a pressure ulcer starts at stage 4. Stage 4 means that it has been festering for a while. I also say this because I was told that the wound was improving and evidently it was not so I guess it is lying negligence then. Why would the nursing home allow it to progress this far because he can not walk and he can not turn himself. I understand that pressure ulcers are very common if a person is bedridden. I just don't understand why they allowed it to progress to stage 4 without sending him to the hospital which is approximately 2 miles up the street.
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