Vet Home Errors Caused Actual Harm

By Walter F. Roche Jr.

A Pennsylvania nursing home serving veterans failed to give a patient needed treatment resulting in "actual harm," including hospitalization and surgery to treat necrotic pressure ulcers, according to a state Health Department report.
Cited by state surveyors was the Southeast Veterans Center in Spring City Chester County which was the subject of an Oct. 10 inspection to determine whether the facility met the minimum requirements for participation in the federally funded Medicare and Medicaid programs. The report concluded that the veterans center did not meet those standards.
The facility failed to monitor and assess the patient's pressure sores and failed to provide necessary treatment for those sores, the report states, adding that those failures resulted in actual harm to the unnamed patient.
Administrators of the 238-bed state run nursing home did file a plan of correction in response to the report and promised to examine each current resident for evidence of pressure sores and to institute a re-education program for employees and to set up an audit program to ensure that all patients get the proper pressure sore care.
Officials of the state Department of Military and Veterans Affairs, which runs state veterans homes, did not respond to requests for comment.
The patient, according to the report, suffered from diabetes and multiple sclerosis and required the assistance of two aides to get out of bed. He also had suffered a stroke.
A review of patient records showed the patient needed to be turned and re-positioned and examined at regular intervals, but records verifying those actually occurred were missing. The records indicated he was only re-positioned twice between July 11 and July 15.
"There was no evidence wound treatment was ordered," the report also states.
As his condition worsened the patient was transferred to a hospital for treatment of a wound infection.
He then underwent surgery for a "necrotic infected stage four sacral decubitus.
"The facility failed to provide the services ordered in the plan of care and failed to identify, assess, monitor and provide treatment necessary in preventing skin breakdown," the surveyors concluded.
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