<
Back to Previous Page
Neglect in Nursing Home in New York
Nothing like a nice warm compress for a sore back after a long day! That’s what Joseph Kaufman’s elderly father thought. It had worked for him, so he suggested it to staff of the residence where his 51-year-old son lived. Joseph Kaufman had lived in the group home for 15 years. Mildly mentally retarded with psychiatric difficulties, Mr. Kaufman had cerebral palsy and required the use of a wheel chair. Because of his physical limitations, Mr. Kaufman required staff assistance with certain activities of daily living, but was fairly independent in others, requiring just some staff prompts or reminders. Verbal, friendly, with a great sense of humor, Mr. Kaufman worked weekdays in a vocational program, which he enjoyed. Aside from osteoporosis and periodic skin breakdown, caused by his obsessive scratching, Mr. Kaufman enjoyed relatively good health until shortly before his 52nd birthday. At that time, Mr. Kaufman developed swelling and cellulitis of the right leg and was hospitalized. His hospital course was complicated by renal problems and pneumonia. However, after about a month he was stable and at his pre-hospital baseline health status. He was discharged back to his home. Shortly after his return to the residence, Mr. Kaufman began to complain of lower back pain. His father – who visited his son regularly, was his legal guardian and was well-known to staff – suggested that staff apply heat to his son’s lower back.
As the house didn’t have a heating pad, Mr. Kaufman’s father suggested a bean bag be used by heating it in the microwave. Staff began using the bean bag or a dampened towel, warmed in the microwave for up to 90 seconds, to apply heat to Mr. Kaufman’s lower back for 30 minutes. Mr. Kaufman seemed to derive relief from the treatment and would ask staff to apply the home-made remedy when he was experiencing pain. Meanwhile, because of the back pain, Mr. Kaufman was seen by his primary physician. The doctor, aware of Mr. Kaufman’s osteoporosis, suspected compression fractures of the lower spine and ordered x-rays. One morning, a staff person assisting Mr. Kaufman with his shower noticed a burn mark on his back about the size and shape of a brick. The skin was bright red and sloughed off when the staff member touched it. It was quickly realized that this was the result of a heat treatment from the previous evening. A staff member had heated a moistened towel folded into a rectangle in the microwave for 90 seconds and then placed the towel under Mr. Kaufman’s back while he was lying in bed. Mr. Kaufman fell asleep and the staff person could not recall how long he had left the heated towel under his back. A nurse was notified who examined Mr. Kaufman, called the primary care physician and described the burn. The physician prescribed Bacitracin BID. Until this point, nursing staff had not been aware that staff were applying heat to Mr. Kaufman’s back. The practice was immediately stopped and an incident report completed. Four days later, as Mr. Kaufman was complaining that the burn hurt, he was seen by his primary care physician. The physician diagnosed an acute thermal burn. The wound was blistering, with some exudate and weeping, but no infection. It was during this visit that returned x-ray results led to the diagnosis of compression fractures of the lower spine. The fractures were the likely cause of Mr. Kaufman’s persistent back pain. The physician ordered Silvadene BID and Telfa dressings for the burn and Lortab for pain. He asked to see Mr. Kaufman again in a week if the wound was still open. Over the next eight days, Mr. Kaufman’s wound was examined by a nurse only once. She noted that there were no signs or symptoms of infection, but her note did not describe the wound’s appearance.
On the eighth day, Mr. Kaufman was taken to a hospital for a recurrence of swelling and cellulitis of the legs. At the hospital, medical personnel saw Mr. Kaufman’s back wound which they described as a third degree burn, foul smelling with excoriation, eschar and cellulitis. The burn site had become infected, calling into question the adequacy of care and nursing oversight at Mr. Kaufman’s group home. The hospital contacted the Commission on Quality of Care and Advocacy, prompting investigations by both the Commission and the agency operating the group home. In time, with treatment, Mr. Kaufman’s wound healed and the medical condition which prompted his hospitalization was stabilized. He returned to his group home. The investigations concluded that Mr. Kaufman was the victim of neglect. Although staff were well intentioned, they initiated a medical treatment (application of heat for pain) without consulting medical professionals, causing Mr. Kaufman’s burn. Further, although staff dutifully changed Mr. Kaufman’s dressings and applied ointment to his wound twice daily, they failed to detect obvious signs of infection, and no notes were written describing the wound in order to track the progress of healing, or lack thereof. Nursing staff also failed to provide effective oversight of Mr. Kaufman’s wound care. In the eight days before the infection was discovered upon his admission to a hospital for a different reason, there was only one nursing assessment of Mr. Kaufman’s wound. The assessment did not describe the wound, nor did it comment on its progress in healing; it simply stated “no signs or symptoms of infection.” This note was written five days prior to the hospitalization.
|
