South Carolina LPNs Arrested For Not Changing Wound Dressings

[NRSKarenRN, BSN, RN]

Attorney General getting involved with wound care not being provided by individual nurses is unusual as FACILITY is held responsible. 

Facility inspection reports can be found at Medicare Compare website.  

Magnolia Manor - Spartanburg  10/4/2022 Health inspection report notes  Police had been called by Social Service director (don't understand why)  due to resident complaint of not having wound care provided --a repeat issue.   CMS investigation done revealed wound care not being done along with some LPNS documenting care as being provided when interviews conducted confirmed wound care was not provided to patient, and nurses admitted lying to administrator ---  that's healthcare fraud, especially if care was billed for payment. Surmise this is why Attorney General office got involved. 

Quote

 

Based on review of the facility's policy, record reviews, observations, and interviews, the facility neglected to provide wound care for 1 of 3 Residents (R)1, R2, and R3 per physician orders.

Review of R1's Physician orders dated 8/30/22 revealed an order to apply xeroform and cover with abd pad and tape, change daily.
Review of the Treatment Administration Record (TAR) revealed wound care for R1 on 9/10/22 - 9/11/22 was documented as refused by R1, when it was not.
Review of R1's progress notes revealed: 09/10/2022 02:29 PM Resident asked to receive treatments after dinner. This nurse will administer treatments at PM and document. 09/10/2022 06:06 PM This nurse went into residents' room at PM to do treatments and this resident refused 2x stating he was tired.
During an interview on 10/3/22 at 1:35 PM, R1 revealed he never refused to have wound care provided to him. R1 revealed he did not receive wound care on 09/10/22 and 9/11/22 and said he would not refuse wound care because he did not want a hole in his buttocks.

During an interview on 10/3/22 at 1:50 PM, the former Administrator reported Licensed Practical Nurse (LPN)3 came to him to discuss wound care. He [former Administrator] was told that R1 did not refuse wound care on 9/10/22 - 9/11/22 as documented in his progress notes. The former Administrator was also informed R1 had complained to staff that he was not provided wound care over the weekend. The former Administrator stated LPN1 and LPN2 initially reported that wound care was provided to R1 and after they were interviewed several times both LPN1 and LPN2 admitted that wound care was not provided to R1...

During an interview on 10/3/22 at 2:06 PM, the Social Service Director (SSD) revealed R1 reported to the SSD that he did not get wound care over the weekend. The police were called and spoke with a lot of the residents. R1 reported that no wound care was performed on Saturday 9/10/22 and Sunday 9/11/22. Friday 9/10/22 was the last time wound care was provided for R1 and wound care should have been done daily if the orders are current. The SSD revealed she notified the Director of Nursing (DON) and former Administrator that R1 did not receive wound care but did not get a follow up on the outcome of the investigation. SSD revealed, to her knowledge, the facility investigation revealed the allegation of wound care not being done was substantiated and the LPN1 and LPN2 were immediately suspended. She reported R1's progress notes documented he refused wound care but R1 revealed he did not refuse wound care on 9/10/22 and on 9/11/22. SSD further revealed after the facility investigation, LNP1 and LPN2 were terminated....

..During an interview on 10/04/22 at 12:32 PM, LPN4 revealed she was currently on suspension. She was suspended last Thursday on 09/28/22 because another nurse LPN3 accused her of documenting wound care when she had not. LPN4 further revealed she had provided wound care to R3 and documented the care but LPN3 reported to the DON that LPN4 did not provide R3 with wound care. LPN4 revealed LPN3 presented a glove with a crumpled up old wound dressing and reported the dressing had an old date as proof wound care was not provided and she was suspended..

 

[Tweety, BSN, RN]

The facility is going to have to answer for some of this.  

My other question is how long did the dressing not get done and was documented that it was done.  Was it just one shift?  

Documenting care as important as wound care, that you didn't provide is fraud.  It's unethical.  If staffing doesn't allow you do basic care, it still has to be done.  The next shift should have done it or bump it up the chain and document that.  

I'm not sure they should have been arrested, but they and the facility need to be held accountable.

[FiremedicMike, RN, EMT-P]

vintagegal said:

This is troublesome. Has it come to the point where you, as a healthcare worker, have to additionally prove you're completing tasks outside of the charting? Should we hire someone to follow us with video cameras ? What is this country coming to? I'm seriously frightened as a nurse working in these dangerous times. This is now the second mainstream account of a healthcare institution having workers arrested to cover their own behinds. If these nurses intentionally didn't change a dressing, it's because they thought they could get away with it essentially, most likely due to lack of management and leadership. The institution wants to forego all responsibility and throw the nurses under the bus instead of coming clean about their role in this nonsense. BON should be the authority here, not the police. We need more info on if this was truly intentional, oversight, or overworked staff. I wonder what their nurse to patient ratios are.... I also would like to know if anyone else had difficulty with this wound care or with this patient. Playing devils advocate maybe they felt like it was outside of their scope- who knows? We need more insight into what occurred. The BON could have been instrumental in finding these things out and escalated up to police if there was proven intent to harm/neglect/abuse.

Hold up, you think it's the facility's fault that these nurses didn't change those dressings?

 

[Nurse Beth, MSN]

KathrynRNBSN said:

complaint 2.pdf  The facility was cited (attached) Without actually doing the investigation, which would be extensive, it is difficult to say although I think it's a very slippery slope. 

Thank you for the info

[Leighsalu, RN]

Arrested for not changing dressings?  Keep arresting nurses for this and you won't have any nurses left.

[vintagegal, BSN, DNP, RN]

FiremedicMike said:

Hold up, you think it's the facility's fault that these nurses didn't change those dressings?

Absolutely, they should be in charge of 1) who they are hiring and 2) what type of work is being done. Why was this problem not rooted out sooner ? You're just going to let two nurses neglect a patient and all you're going to do is take pictures and call the cops? What about keeping patients out of harms way? Where was the management and oversight of an RN?

[JKL33]

Is it just my reading of this or does the issue with R1 center around whether he actually did or didn't refuse wound care (3 times total)?

Who knows what the truth is because while it is easy for a nurse to document something false (such as a refusal), it is also easy for a patient to claim they never refused when in fact they did. For example if a patient is indeed getting "a hole in [your] buttocks" 3 weeks later it's awful easy to believably claim they never would have refused care--because who would want a hole in their buttocks. No one. So "obviously" he wouldn't have refused. But he still could have indeed refused. Maybe he thinks that he was supposed to be asked 3 more times sometime later in the evening and then he would have been ready.

The bottom line is it doesn't seem like we know many facts.

[FiremedicMike, RN, EMT-P]

vintagegal said:

Absolutely, they should be in charge of 1) who they are hiring and 2) what type of work is being done. Why was this problem not rooted out sooner ? You're just going to let two nurses neglect a patient and all you're going to do is take pictures and call the cops? What about keeping patients out of harms way? Where was the management and oversight of an RN?

OK, just so I'm clear, you feel the nurses are responsible for their own actions as well, right?

Leighsalu said:

Arrested for not changing dressings?  Keep arresting nurses for this and you won't have any nurses left.

Don't suck at your job to the point that you're falsifying documentation and causing patient harm.  If that scares away the types of nurses that would allow this to happen, I'd say win-win!

[Pattisparo]

I would not ever return to a subacute or nursing home setting.  This is a sad story all around and I hope these two nurses get a fair shot here. 

[RosesrReder, BSN, MSN, RN]

Leighsalu said:

Arrested for not changing dressings?  Keep arresting nurses for this and you won't have any nurses left.

They have AI in the works for that too.  Ask Mayo.

[hppygr8ful, ASN, RN, EMT-I]

When I was in nursing school I was taught to write with a sharpie my first name and date on my dressing change. I still do it twenty years later though many of my co-workers find the practice strange.

[Idealista]

hppygr8ful said:

When I was in nursing school I was taught to write with a sharpie my first name and date on my dressing change. I still do it twenty years later though many of my co-workers find the practice strange.  

It may be "strange" but it can save your cookies! I put my initials and the date of change, whether a wound or a Fentanyl patch, as a matter of routine. Why not do it, for heaven's sake? It seems that nurses have to defend themselves from everything in the healthcare setting today - from violent and/or litigious patients to corrupt or uncaring management to incompetent co-workers. It takes only a second...and it could save a license.