A female resident of Oakpark Healthcare Center died on 1/27/2013 from an infected and gangrenous foot wound. The resident was admitted to the facility with kidney disease, dementia, and diabetes. On 11/12/2012, she was observed with a Stage 2 left heel wound, but nursing notes since that date failed to document the condition or progression of the wound. The nursing staff also failed to monitor the wound for signs of infection, or obtain a wound consultation in a timely manner per physician's orders on 12/19/2012.
During the painful progression of her pressure sore, the resident repeatedly cried out "help me" to nursing staff. Her cries for help were not linked to her wound; rather her continuous pleas were labeled "psychotic." The resident's physician and the facility's staff responded by increasing her prescriptions for psychoactive medications, including Haldol, Ativan, Depakote, and antidepressants. The cocktail of chemical restraints was unable to stem the resident's uncontrollable and excruciating pain.
The resident's care plan did not include a determination of whether the screaming for help was related to severe pain from her gangrenous and ultimately fatal wound.
Originally, the facility was given a deficiency and no monetary fine for this horribly shocking case. After an appeal, the facility was cited and assessed a $75,000 fine but not until over two-and-a-half years after the DPH investigation was initiated.
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