Wound Care Standards in Nursing Homes

BarbPick · Dec 10, 2003

My cousin Susan works in a nursing home.

I asked her about wound care and it is usually done as a clean procedure. Sterile gloves are not worn unless someone specifically orders them to be done so.

I also asked her about this situation as you described about your dad, and she said someone dropped the ball.

When someone is admitted in her facility, a poloriod is taken of the slightest change in skin care. She told me exactly how it is done and she said the iodoform gauze is packed with sterile Qtips and pick ups from disposable suture removal kits. The jar of gauze is dated and closed with the tail left exposed is cut off and only clean iodoform gause is packed. When they do wet to dry dsgs liquids are poured into sterile 4x4's on the paper, and placed using the pick ups in the suture removal kit.

Something went wrong, did they not turn your dad at all?

Jay-Jay, RN · Dec 10, 2003

Barb, I honestly don't know. I think it was because he couldn't reposition himself in the wheelchair to ease the pressure, due to his cognitive decline, and what may have been a small stroke.

Also, we do wound care in the community as a clean procedure. We would use sterile gloves if we ever had to pack a wound by hand (no forceps or sterile q-tips available.) We clean and re-use forceps (but only for the same patient) by boiling them for 10 minutes in a covered pot. Our outcomes re. infections acquired while patients are on service is excellent, much lower than the hospitals.

I was really, really shocked by what I saw tonight, and don't know what to do. I am upset with the nursing home on a number of issues. They missed the stroke...I was the one who first spotted it. They missed a bout of pneumonia, ignored me when I told them THREE times that there was something wrong with my dad. And he was being over-medicated with Risperdal. He came from the hospital on it, and it was turning him into a zombie. The nursing home did cut the dose back twice, then took him off it completely when he had the stroke. Then, I did an internet search on it...and guess what I found?? A Health Canada bulletin warning that it should NOT be used in elderly people suffering from dementia, because it has been associated with an increased number of CVA's!!

BarbPick · Dec 10, 2003

Jay Jay,

you know what to do, we just don't like to go there. When I did mostly High tech home health, the best way to screw up a central line was to send the patient to the hospital. They would come back with green stuff around the line and most ports clotted.

I have seen some really stupid rational, but bottom line, all patients are turned q 2 says Susan. Now I have tried to auction Susan off on EBAY with no takers but she like a stopped clock is right twice a day. She said her care techs do q2 turn rounds and she sees everyone butt daily(if possible). She has made some of my forensic stories sound mild when she talks of some patients admitted with decubus ulcers. How a patient needed a foleyand a colostomy due to skin break down.

You need to make a few calls. Start with his doctor. You know who you really have to call, these people are taking care of your neighbor's parents as well.

Barbara

Home Health Columnist / Guide · Dec 10, 2003

Despite pressure releaving devices, it sounds like your dad's wound developed from prolonged pressure and shearing forces--even 2-3hrs sitting in a chair with just a little slide forward putting pressure on overstreatched skin is enough to create your dad's ulcer.

Insurance Companies in my area do not pay for forceps! Our agency has sterile Qtips only for packing wounds. I do all my wound care clean technique in home oo nursing home BUT I don a clean pair of gloves after old packing removed, then again after wound cleaned so have clean pair on to do wound packing. I paractice wound care as Barb Pick described too re packing strip container.

I wonder if your Dad has a sinus track type infection extending deeper. Full strength betadine too toxic to tissues, iodasorb packing gauze is available till foul smeell gone + needs oral antibiotics.

Sorry to hear this has happed to your Dad who you love so much. Hoping better days ahead, Insists on wound care nurse consult. Also he needs supplement shake to increase protein stores. Arginaid was the drink Iused to help my Dad's foot heal last year

--see what 's available in Canada ( L arginine is the ingredient stimulates protein production). He'll need Multivit with Zinc too.

I'm watching my Dad like a hawk these days as had CABGX4 11/13 with minor complications, phlebitis from IV in L arm, incision healing ok, pneumonia resolved but still has rales. Reordered Mini neb last Friday "you can't do that, your not a doctor" after call to PCP. He had First class treatment in ICU "because of my status at agency" now he thinks i walk on water.

:roll

{{{{{{{{{{{{{Here's hoping better days ahead. }}}}}}}}}}}}

LydiaGreen · Dec 10, 2003

Betadine... soaked on packing in a stage 4 decubitus ulcer? I know you are serious and that this is not a funny issue at all, but my first thought was, "You're kidding, right?" Betadine may help with preventing the spread of bacteria but it is going to destroy any new tissue that is trying to develop and any remaining healthy tissue. These ulcerations are painful enough without all of that betadine. Look into DEMANDING alternatives. My nursing class was permitted to attend a two-day advanced wound care in-service last year and count it towards clinical hours. It was put on by Johnson & Johnson here in Ontario and was beyond excellent. I learned SO MUCH from those two days.

Pressure ulcers are avoidable. I have done placements in an LTC and in a hospital with chronic beds (beacuse the LTC has a two year waiting list - these beds are not designated chronic, but there is no alternative). Patients do not develop pressure sores in either of these facilities. Sometimes they are admitted from other facilities with them (or in cases where a loved one was doing their best to care for an elderly person at home on their own but just did not have the knowledge of what could happen). We have two nurses who are beyond expert in this field and they design a course of action for each patient's individual needs and wound.

I would be more than a little upset if this was my father (my father had a severe CVA and was in a wheelchair for two years prior to his death and never developed any skin breakdown at all). Your father's inability to adjust his position in his wheelchair should have been assessed and that cushion in place, if it had been, he would not have developed the ulceration.

I feel badly for your father, and sympathize with you. Write a letter of complaint, keep a copy, and keep making noise until things are changed at that facility. I agree with Barb, your neighbours' loved ones are in that facility too. Unfortunately, the average person has no knowledge that these types of injuries can be avoided and may think it is normal for them to occur in the elderly. Nurses and other health care professionals with the knowledge, should share it. Good luck, and I hope that your father heals quickly.

Jay-Jay, RN · Dec 10, 2003

Originally posted by LydiaGreen
Betadine... soaked on packing in a stage 4 decubitus ulcer? I know you are serious and that this is not a funny issue at all, but my first thought was, "You're kidding, right?" Betadine may help with preventing the spread of bacteria but it is going to destroy any new tissue that is trying to develop and any remaining healthy tissue.

:rolleyes: Lydia, you would not BELIEVE the number of doctors out there who still LOVE Betadine packing! We have two very excellent plastic surgeons at a local hospital, who do a very large percentage of the complex wound care for that area, and it's taken most of the 5 years I've been at this job for our WORN to educate them away from this. Now, they will agree to our WORN's favorite remedy: iodosorb ointment. It has the antibacterial action of iodine without the harmful effects on granulating tissue. My dad was seen by a wound specialist at a local hospital, and HE was the one that prescribed the Betadine.

And yes, I agree, this COULD have been prevented if more careful attention had been paid to my dad's buttocks and position in the wheelchair when they got him up again after that week of bedrest. I haven't found out details, but I'm willing to bet he was up in that chair for most of the day on Wednesday, and possibly on Thursday as well.

Sweetberry · Dec 10, 2003

Hello,

I, too, am shocked at the wound care done at the nursing home I work at (I'm a nurse's aid while I go to school). Everything is done with clean technique, even completely open wounds. One nurse once told me that "in LT care, they don't waste money on sterile supplies because most of the people are going to die of something else before the infection will get them anyways." What an AWFUL thing to say, and how INACCURATE AND WRONG! The majority of the people in LT care live many years quite healthy and happy, simply disabled!

Like someone said already, write a letter complaining to the HEAD of the health district AND the head of the facility where you are working (that will get the show on the road)... Believe me, if you only write one letter, it can simply get chucked in the gargage (I've seen it happen many many times).

And talk to the doctor yourself (I'm sure he doesn't want your father to be receiving that awful care.... If he realizes what is happening, he may order STERILE dressing changes BID at the care home.

And make sure that it is only the RN doing the dressing changes, not the aids or CNA's. If you want, be there and do the dressing change once or twice yourself, with the RN watching, so she can see how meticulous you are about wanting it done right.... Write/make a poster about HOW TO DO IT!!!

And make a LARGE poster to hang over his bed about the positions to lie your father in so that the sore doesn't get worse and how ofter to turn him (draw pictures and use colors).

And make a sign for on his W/C for how long he can be up in his chair at a time for, how to position him in it, if there are any special cushions for in it (sometimes cutting a cushion can take pressure off the sore - talk to OT/PT or do it yourself) and hag or tape this sign to the chair where it is ALWAYS visible!

I hope these ideas work.... These are some things that have been used in the nursing home I work at that have been helpful with residents and their families....The posters are EXTREMELY helpful in MANY different situations.... Just make sure they're visible and easy to read/understand....

Take care!

CoffeeRTC, BSN, RN · Dec 10, 2003

Jay Jay, I work in LTC and can tell you how wrong this is... Most pressure ulcers are preventable. The first thing I teach my CNAs is "Clean em, Feed em and Move em!" Having a CVA doesn't mean he should get pressure ulcers. How is his nutritional status? Is he on a tube feed or po? Is he being fed by staff if unable to feed himself? What about supplements..increased protien, Vit C, Zinc and Multivitamin q day? We get baseline labs on all of our new decubs and check the albumin and CBC. Next look at mobility and positioning. High risk turned at least 1-2 hrs in bed and 1 hr out of bed. Anyone with high risk is returned to bed after lunch and gotten up for dinner.. what are they using for positioning? Just remember...even the most expensive equiptment isn't usefull unless it is used correctly and pressure is releived. We also get a PT/ Ot and dietary consult.

As far as wound care ?Betadine?? sounds like my one doc who loves to use silvadene on everything... We use clean technique with all of our wounds. I try to maintain as much sterility as possible... Sterlie 4x4s, qtips, packing, NSS. I must change my gloves at least 4-5 times during each dressing. A wound consult would be best for this....hopefully they could teach the nurses something...

Another thing to look at .....a stage IV wound? That is definately something the state surveyors would love to investigate and will show up on the facilities QI report. What did or didn't the facility do to prevent this from occuring... I'd follow up with the DON.

The signs on his w/c and in his room are a good reminder for staff, but I'd talk to the nurses about this first..A lot of our signs were recently taken down..HIPPA regs or something.

Long Term Care Columnist / Guide · Dec 10, 2003

Jay-Jay, one of the first things I would have done had I been your father's care manager would be to get orders for a multivitamin with minerals QD, Vitamin C 500mg BID, and elemental zinc, 220mg QD for 6 weeks (any longer than that, and you risk a copper deficiency). Also high-protein nutritional supplements TID.

The next thing would be to have him evaluated for a Wound-Vac. Like many posters here, I'm horrified by the idea of Betadine anywhere near a stage IV ulcer, and this wound sounds like something that will never be cured by conventional means. We're using the wound vac more and more these days, both in LTC and the hospitals, and while they're not the cure-all for every wound, your father certainly sounds like a candidate. They help heal the wound literally from the inside out by continuously vacuuming the infectious fluids out and promoting the growth of granulation tissue with the use of a special sponge.

Just a few thoughts........I hope things go better for you and your father. I know it's hard to have someone you love in a nursing home, the lack of control is very frustrating, and even in the best facilities, staffing isn't adequate to meet the needs of this very frail population. (That's why I no longer work in LTC---between the paperwork and the continual frustration of never having enough staff or resources to take proper care of the residents, I literally became ill and then got fired for my trouble.) Please keep us posted as to how he's doing.

jnette, ASN, EMT-I · Dec 10, 2003

(((((((((( Jay-Jay))))))))))

Have nothing to add here as the others have already addressed your concerns quite effectively... but I just want to offer support and best wishes for your Dad's recovery.... so glad he has YOU to look in on him and after his wellbeing. I'm so sorry he (and you) are having to go through this.

ktwlpn, LPN · Dec 10, 2003

Originally posted by Jay-Jay
My dad was admitted to a nursing home in June of this year. Recently, he suffered what seemed to be a small stroke, with some impairment of movement on his left side. After this, he began to have trouble with bedsores, as he was not moving himself around enough in the wheelchair to relieve pressure. The nursing home tried different strategies to relieve the pressure, but finally had to put him on bedrest for about a week.

Last Wednesday, I visited, and he was up in his chair for the first time in over a week. They had a new, very expensive cushion for him, and I though everything was going to be okay. Unfortunately, it was not to be. By the time they put him back to bed, his left buttock had a hard swelling about 6 cm. in diameter. It got worse as the week went on, and by Saturday he was running a fever. They sent him to hospital, where they opened and debrided what was now a nasty abcess.

Unfortunately, I had to work on the weekend, so I didn't get to see the wound until today. He's got a stage 4 ulcer, necrotic around the edges, and a little larger than a golf ball, with dark, very foul smelling drainage (fecal odour). Very nasty looking!! They are changing the dressing BID and packing it with Betadine soaked gauze.

Now, here comes the shocker. While I was there tonight, the nurse came in to do the dressing change. She was not wearing sterile gloves. She cleaned the wound with non-sterile 4x4's (no forceps, just held the gauze in her fingers) She then took a length of ribbon gauze that was sitting in a bottle which did not have a lid on it, put it in a non-sterile med cup, and poured betadine on it. She then used her (non-sterile) gloved fingers to pack it into the wound!!

I have requested that a wound-ostomy resource nurse go in and assess the wound, and its treatment. (I also plan to be there myself, if at all possible!) Hopefully, she will teach them a thing or two about proper wound care technique!!

My question for my fellow nurses is: How common is it for nursing homes to have such horrible standards for wound care? I can't blame the nurse...she was from an agency, and obviously knew better, because she actually apologized to me, and said, "This is all they have given me to work with!"

Problem is that often the staff will assume that the expensive seat cushion or mattress will take the place of repositioning...I have had families insist on a nap schedule for their loved one...I am in a latge county run facility and we recently had one of our adon's become gertifed in wound care.She is making a big impact on our resident's well-being..We are fortunate to have her expertise.Maybe you and the wound care consultant can help educate the staff at your dad's home and help everyone....I would perform the dressing changes much like Karen states-I would use what I have available-sterile q-tips to pack the wound with a sterile 4by 4 that I opened and poured the solution on...A Clean glove to remove old dressing and another clean glove to apply new one...We also use the multi vits,vit c,zinc and a protein powder .It also sounds like your dad's wound needs some chemical debridement (we use accuzyme) for awhile-and an antibiotic..Good luck...