Nurse Care of Buckhead complaint alleges inadequate pressure-ulcer prevention during a 28-day stay before sepsis
The complaint alleges that a nursing home did not prevent or adequately treat a pressure wound during a 75-year-old resident’s 28-day stay for respite care. Staff scored him as at risk for skin breakdown on admission, but the expected weekly follow-up assessments were not conducted or recorded. Staff charted a Stage 2 sacral wound within two weeks, and later noted it was getting worse every day despite zinc treatment. By early January the wound was unstageable, and the resident was sent to a hospital, where providers found dehydration and a kidney injury.
Overview
This page concerns a public complaint alleging that a nursing home let a resident’s pressure wound reach the point of suspected bone infection.
Chronology
The complaint alleges as follows:
- The resident, 75, was admitted on December 12, 2022 for short-term respite care, with no skin breakdown noted at admission.
- His Braden Scale score that day was 15, indicating risk. No further weekly Braden assessments were conducted or recorded as expected as his condition changed.
- His December 13 care plan for skin breakdown lacked interventions such as padded booties, a turning schedule, a pressure-reducing mattress, and a chair cushion.
- On December 23, 2022, staff recorded a new Stage 2 sacral pressure wound, and later records show gaps in documented turning and repositioning.
- On January 5, 2023, staff noted the wound was worsening daily despite zinc treatment, and new orders were not written until January 8.
- On January 8, 2023, staff reported him lethargic, and he was sent to Grady Hospital. Providers there found dehydration and a large infected sacral wound.
- Doctors performed emergency debridement for suspected bone infection, and he remained hospitalized until February 11, 2023.
Alleged failures
The complaint alleges the following failures:
- Staff did not accurately assess his risk for pressure wounds or build a care plan suited to his needs on admission.
- Staff did not consistently turn and reposition him or document that they had done so.
- When an aide found an ’open area’ on December 30, 2022, nurses did not assess it further. The physician and/or responsible party were not notified.
- Staff did not perform a urinalysis that had been ordered, leaving a urinary tract infection undiagnosed until he reached the hospital.
- The complaint pleads professional negligence, ordinary and managerial negligence, negligent hiring, retention, and training, violations of long-term care residents’ rights, and punitive damages. It attaches an expert affidavit under O.C.G.A. § 9-11-9.1.