Should I report my nursing facility for neglect?

[Figglehorn68]

I'm a CNA who just started a new job at a nursing home. One of the residents that I now care for has a stage 4 bed sore. Before I started working here, I'd never even seen a stage 4 bed sore. At the previous nursing home I worked at for almost 2 years, I never encountered anything beyond a stage 2 bed sore, the reason being that we always took necessary measures to ensure that the sore would heal instead of become worse. I obviously do not have a medical degree, but it seems to me that a stage 4 bed sore is something that could only be the result of neglect. I'm not sure if the resident's family is aware of the severity of this bed sore because when I began asking questions to the charge nurse, she dodged them all which I thought was awkward.

My question is, how can I be sure that the right people know about this resident's condition? And why is the nurse so "hush-hush" about it? Have any of you ever encountered a patient with a stage 4 bed sore that wasn't a direct result of severe neglect? I don't exactly trust this particular nursing home because they have a bad reputation and when I first started training, they literally told me to never chart anything as "N/A" because they get more money from medicare this way. For a nursing facility to openly support medicare fraud is also something new to me. What should I do?

[Esme12, ASN, BSN, RN]

Welcome to AN!

Thread moved for best response

[Rose_Queen, BSN, MSN, RN]

You should be able to find a number for an ombudsman posted within the facility. If not, you can always try here: NORC - Locate an Ombudsman and State Agencies. :: Locate an Ombudsman

Obviously, I'm not there to look at the patient or know the history of the patient's care. It may be neglect; it may be the patient refuses all care that would prevent pressure sores (i.e., turning, change of position, adequate nutrition, etc).

[kcochrane]

It's possible to that they came from hospital with it.

[Figglehorn68]

I know she doesn't refuse cares, at least not from what I've witnessed so far. She always lets me re-position her and change her depend. I haven't seen her combative in the least bit. In fact, she hardly talks at all when I go in there.

[Figglehorn68]

I thought of that too which is why I specifically asked the CNA I was working with. She said the resident didn't come from the hospital but her room used to be in a different wing of the nursing home. Although I'm not sure I can take her word for it because she's also fairly new to the facility.

[AmyRN303, BSN, RN]

In a large facility LTC/LTACH my first semester, I saw probably a dozen stage 4s, and not due to neglect. Nutrition status plays a large factor. I'll leave it up to those with more experience than I have, but I don't believe a stage 4 is always due to neglect.

[VivaLasViejas, ASN, RN]

People who jump to conclusions often make bad landings.

You cannot assume a stage IV pressure ulcer is the result of neglect. I have seen people literally go to bed with a stage II and wake up with a III. This usually doesn't happen until the latter phases of the dying process, but there are plenty of times when nursing staff are doing all they can to reposition, supplement, clean, hydrate, and change dressings, and a wound will STILL progress.

Also.....the nurse does not have to discuss any of this with you, as all communication is on a need-to-know basis and you don't really have a need to know. You have a duty to keep the resident clean and dry, to reposition her per the care plan, and to notify the nurse of changes you observe, but you don't necessarily have the right to know what's being done or why.

Now, when I was a charge nurse I frequently let the CNA's in on what I was doing and why I was doing it, because it not only taught them something but also encouraged them to be invested in that resident's care. Perhaps your nurse feels differently. And you could be right---it could very well be neglect. But don't just go running off to the nearest authority without having observed that the resident is not being turned and changed regularly; they have to investigate every single complaint, and false claims take time away from the cases that truly are neglect or abuse.

I'm not saying you should never make a formal complaint, but just to be sure of your evidence before you do it.

[CapeCodMermaid, RN]

I have been in the business for more than 30 years and have NEVER seen a stage four pressure ulcer that was the result of neglect in the facility. I've had people admitted from home with stage 4's big enough to put two fists in (we ended up healing that one) and I've seen residents from the hospital with stage 4's. You cannot assume that the nursing home is neglectful. We have residents at the end of life who are turned every hour, on a specialty low air loss pressure relieving mattress who still develop stage 4 ulcers. If people don't eat and are going to die, chances are they will develop an ulcer despite every intervention.....do a BING search of "Kennedy Ulcers" before you call any regulatory body.

[courtneyyyBSN]

There are SO many risk factors.

However, I'll give you the other side of it. I worked in an acute care hospital for a couple years. We had people from the nursing home come with Stage IV pressure ulcers FREQUENTLY. The facility would often NOT tell us about the wounds. Then we would assess them and note they have a Stage IV on the sacrum, a Stage II on bilateral elbows, a Stage II on the scapula, etc etc. So it CAN and HAS happened at nursing homes. Even during clinicals while in nursing school, I saw MANY different stages of ulcers at nursing homes and hospitals. It varied, not just one is to blame.

It can depend SO much on the comorbidities of the patient as well. Not to mention, some of the patients had a clear level of consciousness and would REFUSE all care when concerning turning except when they wanted it, EVEN with thorough education on the importance of turning every 2 hours. Some patients have nutrition issues, many of ours were patients with kidney disease and their albumins were VERY low.

SO coming from a hospital standpoint, you can NOT assume it's all the nursing home's fault. HOWEVER, you MUST document what you see. Therefore, we would document all the wounds upon transport to our floor. You must cover your butt. From an RN's perspective, we're covering our license. From your perspective, your certification.

Don't throw them under the bus just yet. Keep a close eye on what's going on within your facility. IF you do notice any form of neglect, report it. It's your duty as an advocate for the patients. You should be able to do this all anonymously.

Good luck to you on your new job!

[ChristineN, BSN, RN]

I work in a wonderful hospital where the nursing staff is very competent and committed to pt care. However there have been cases when we have had ICU pts that have been too sick to turn, that end up with Stage III and Stage IV's. It isn't ideal and no one likes seeing pressure ulcers, but sometimes when you are on the vent, very unstable, etc. It can happen.

[noc4senuf]

What is the care plan saying for how to care for this resident? Does it list all the interventions? It would also list all the problems relating to the pressure area. Have you spoke with a nurse, supervisor, anyone? As others have noted, there are many factors involved. Many years ago, it was more suspect to think they were caused by neglect but, more often these days they are unavoidable and documentation is in place to justify why they are unavoidable.