LOYAL. LOCAL. COMPLETE.
PARIS – According to a report filed by the Illinois Department of Public Health (IDPH), alleged lapses in staff communication resulted in the hospitalization of a local nursing home resident after maggots were discovered in a wound on the resident’s foot.
The extensive report, dated Aug. 7, 2024, and acquired by The Prairie Press through a FOIA (Freedom of Information Act) request filed Monday, Sept. 16, states “the facility failed to monitor and prevent a wound from worsening, failed to prevent new wounds from developing, failed to implement pressure reducing interventions and failed to complete treatments as ordered for three of three residents reviewed for pressure ulcers in the sample list of three.”
“This failure resulted in (a resident) requiring hospitalization for a maggot infestation of (resident’s) wound,” the report concludes.
After the resident was hospitalized July 31, analysis of the wound led to a diagnosis of osteomyelitis, or a bone infection. The resident was placed on a pair of antibiotics for six weeks to combat the infection.
The first intervention from staff mentioned in the report was recorded in February. The wound was classified as a pressure ulcer, or bed sore: a soft tissue injury resulting from prolonged pressure on a body part.
According to documentation cited in the IDPH’s report, an order for daily treatments of the wound was placed April 16, and set to run through July 17. The order was not signed off as completed on July 15. The same treatment administration record (TAR) cited in the report also indicates a second order, dated July 17, to change the resident’s clear wound dressing “as needed” was not signed off or marked as complete from July 17 through July 27. The order also indicated an unidentified wound nurse practitioner was the only individual cleared to remove anything below the clear dressing, and that the wound nurse would provide care weekly.
A corresponding note from the wound nurse practitioner explains the resident’s wound, located on their right heel, was to be treated with a skin graft, secured with two wound dressings and checked daily. The exterior dressing was to be changed by staff whenever needed.
A one-time treatment was ordered for the resident July 23 after a licensed practical nurse (LPN) contacted the wound nurse and informed them the clear dressing was missing from the resident’s heel. Days later, more notes documented the same LPN could not find the appropriate clear dressing and noticed the rest of the wound dressing was “slipping down.”
“(LPN) reinforced the dressing with foam gauze dressings,” the report reads. “There is no documentation that (the) Wound Nurse Practitioner was notified.”
From that point, the condition of the resident’s wound worsened. On July 30, the resident’s shower aide reported to the LPN that “(the resident)’s odor was really bad and (she) thought (she) was going to throw up from the smell.”
In a subsequent interview, the LPN stated she relayed the shower aide’s account to a business office manager who acted as an assistant to the wound nurse practitioner. The conversation was not documented and the wound nurse practitioner was not notified. The report states the LPN claimed staff members were told not to touch the wound dressing.
Several other staff members and certified nursing assistants (CNAs) recalled a strong odor coming from the resident and their room. One staff member was told the odor was likely “coming from the skin graft.”
Per the report, the wound nurse practitioner later stated “The nurses should have been monitoring the secondary dressing everyday.”
She also “confirmed that she was not made aware of the strong pungent smell coming from (the resident)’s wound and should have been made aware.”
On July 31, large amounts of odorous drainage and maggots were discovered underneath the dressing by the wound nurse, who requested the resident be sent to the hospital to be evaluated.
According to testimony in the report, the resident “stated (to staff) that the wound was smelling but staff didn’t do anything except agree that it smelled.”
The resident also reported that their heels were still touching the bed even with foam rings around their calves.
Several corrective actions were detailed by Paris Health and Rehab Center in the report, including:
In an official response issued to The Prairie Press, Cindy Crable, CEO and Administrator of Paris Health and Rehab Center, acknowledged the incident.
“Paris Health and Rehab Center always makes our residents’ care our top priority and we treat them like family. When a situation develops that challenges this, we act quickly and, if necessary, make rapid changes to improve upon our care,” the statement reads. “One of our residents developed a wound complication in late July. We determined the resident needed additional medical care and quickly received it according to our protocols set up for these circumstances. We’re very happy to report that the resident is on the mend and in good spirits.”
Later in the statement, Crable said patient-specific details can affect the healing process.
“I would like to note that many factors affect the care and healing of wounds, as each one is unique. In fact, some can be quite challenging,” Crable said. “That’s why we very frequently check each of our residents for wounds and their healing progress; that’s part of our daily care. Also, Paris Health continually trains our healthcare team on the latest advances and best practices in wound treatment.”
Per Crable, the facility complies with IDPH guidelines governing wound care.
“The Illinois Department of Public Health thoroughly reviewed our wound care practices shortly after this incident and the following week reported, ‘All deficiencies have been corrected, and no new noncompliance was found,’” the statement concludes.