George Herman is a 74 year old Caucasian male who was living in a long term care facility. The records began with his admission to Community Hospital after a syncope episode that resulted in a fall. X-Rays at Hollywood Community Hospital did not show any injury from his fall. He remained at Hollywood Community Hospital from 3/13/08 to 03/17/08. The only document for review of this admission was the History and Physical.
On 3/17/08, Mr. Herman was admitted to Crest Healthcare. A Fall Risk Assessment was not fully completed at the time of admission. The assessment was started and not completed knowing that Mr. Herman had a history of previous falls. A Care Plan was not developed for fall risk prevention interventions at any time during his stay at Imperial Crest Healthcare.
On 3/25/08, Mr. Herman was found on the floor when he fell out of his wheelchair. A Fall Risk Assessment and Care Plan were not developed at the time of this fall. The physician was notified and ordered a Geri chair and soft belt restraint for safety.
An MDS was not completed within fourteen (14) days of admission that would have identified Mr.Herman’s previous history of falls. The Admission Nursing Assessment indicated that he had multiple areas of redness to his left hand and buttocks. There were no further skin assessment documents available in the record.
On 4/2/08 at 5:45 am Mr. Herman was found on the floor next to his bed. There was no documentation as to how long he had been on the floor. There were no ADL (activities of daily living) sheets available to indicate any rounding to check on residents. The last nursing documentation was sometime on the 3-11 shift the previous evening. There was no documentation as to the time of the documentation.
Mr. Herman was transferred to Hospital for evaluation. A CT of his head showed a large left Subdural Hematoma. He was comatose with snoring respirations and frothy sputum. He required Intubation and Ventilator Support. A Chest X-Ray showed he had Pulmonary Edema.
Mr. Herman was taken emergently to surgery where he had a Craniotomy and Hematoma Evacuation. He tolerated the surgery well and was transferred to the Intensive Care Unit.
Mr. Herman soon awakened in the Intensive Care Unit and was responding well while still on the Ventilator. He had a nasogastric tube for feeding. A prior chest X-Ray had showed Patchy Right Lung Infiltrates that according to his physician were probably due to Aspiration Pneumonia.
A sputum culture showed MRSA (Methicillin Resistant Staphylococcus Aureaus).
There were several records missing in the Hospital documents that included nursing notes, skin assessments, physician orders and progress notes making the review incomplete at this time.
On 4/10/08, Mr. Herman was transferred to another Hospital for subacute management and rehab.
Skin assessments completed at the time of admission to second Hospital indicated multiple skin issues. These issues are listed in a “Pressure Ulcer Tracking Chart” that is included in this report.
The admission History and Physical to second Hospital indicated that Mr. Herman had Bilateral Pneumonia that was growing MRSA.
On 4/18/08, a Chest X-Ray showed that Mr. Herman’s Pneumonia was persistent and unchanged.
Nursing Notes indicated that Mr. Herman was turned and repositioned every two (2) hours and receiving wound care to the multiple sites.
Mr. Herman had been taking oral nourishment until he began to deteriorate. He began to experience swallowing problems and having mental status changes. This occurred approximately two (2) weeks prior to his transfer to Hospital. A nasogastric feeding tube was placed for nutritional support.
An MRI at second Hospital indicated that Mr. Herman had a possible bleed that had reoccurred and needed to be transferred to the hospital. The MRI also showed that he may have had two Small Strokes in addition to the Reoccurrence of a Cranial Bleed.
On 5/27/08, Mr. Herman was transferred to Hospital. He was taken to surgery the following day for a Recurrent Left Sided Subdural Hematoma.
Sputum cultures showed Acinetobacter Baumannii and Pseudomonas severe infections.
While at Hospital, Mr. Herman was diagnosed with a Urinary Tract Infection. Documentation indicated that Mr. Herman had been diagnosed with Diabetes.
On 6/5/08, Mr. Herman was discharged back to second Hospital for continued rehab.
The History and Physical upon admission to second Hospital indicated that Mr. Herman had a “bonafied” Urinary Tract Infection.
Mr. Herman was diagnosed with multiple infections while at second Hospital. These infections included Pseudomonas and Acinetobacter to his right hip wound, MRSA and Acinetobacter to his G tube wound, and Pseudomonas and MRSA to his left hip wound.
On 714/08, Mr. Herman was taken to surgery for Debridement of his Stage IV Pressure Ulcer to his right hip.
On 8/11/08 Mr. Herman was taken to surgery for an Abscess to his Stage IV Left Hip Pressure Ulcer.
While at second Hospital, Mr. Herman developed a DVT (Deep Venous Thrombosis). An IVC filter was placed on 5/19/08 to prevent additional formation of clots.
On 9/15/08, Mr. Herman was transferred to Rehab. His primary diagnosis was Aspiration Pneumonia and secondary diagnosis was Pressure Ulcers.
The Interdisciplinary Progress Notes indicated that Mr. Herman was admitted with severe contractures and multiple wounds. He had an additional diagnosis of Sepsis. The notes indicated there were three (3) dehisced areas to his surgical site that were healing.
On 3/12/09, Laboratory reports indicated a BUN of 115 (7-18) and Creatinine 4.1 (0.7-1.3)
On 3/12/09, a Urinalysis showed that the Urinary Tract Infection continued. The Foley was replaced showing dark urine with sediments and foul odor.
The physician was notified on 3/12/09 and an order given to start Normal Saline at 100 ml for the treatment of Dehydration. Levaquin was ordered for the Urinary Tract Infection.
On 4/14/09, Interdisciplinary Progress Notes indicated that Mr.Herman had developed a Stage IV Pressure Ulcers to his Right Lateral Heel, Left Ischium (previously a Stage IV) and Left Hip
On 4/16/09, a Urinalysis showed that Mr. Herman continued with a Urinary Tract Infection. Levaquin was started for seven (7) days.
On 5/1/09, wound cultures were taken of Mr. Herman’s left heel and left hip. Results showed E. coli, Proteus and MRSA.
On 11/16/09, Mr. Herman was taken to surgery for debridement of his Left Hip Stage IV Pressure Ulcer. Two days later Mr. Herman died.
About the Author
Attorney Steven Peck has been practicing law since 1981. A former successful business owner, Mr. Peck initially focused his legal career on business law. Within the first three years, after some colleagues and friend’s parents endured nursing home neglect and elder abuse, he continued his education to begin practicing elder law and nursing home abuse law.