A background on Steve: Steve had spent 2 weeks in the ICU unit and another week in the step down unit. He had two life saving surgeries and the doctors had to remove a flesh eating bacterial infection from his lower back and buttocks area. The wound was massive and required the wound dressing and packing to be changed every 12 hours. The wound was the size of a football and you could see and touch his spine from inside the wound. Muscle tissue, ligaments, fat tissue were all removed during his two surgeries. The initial infection was gone, but any secondary infection in the wound could quickly become fatal.
On 4/22/2016 I had showed up at 5:00pm to visit Steve. His sister had showed up a short time later. Steve had stated around 6:00pm that he was supposed to have his dressing changed at 5:00pm. With the severity of his injury and his wound being acceptable to infection, it was very important his wound dressing was changed every 12 hours.
Steve hit the nurse call button and an aid came into the room. We advised her that the nurse needed to come in and change Brian's bandage as it was an hour and a half over due and that his shirt, boxers and pajama bottoms were soaked from the leaking bandage.
After some time (15-20 min or so) the aid came back in the room, changed his bedding and he got back into bed. At this time the aid had taken his blood pressure and Alice and I heard her mumble....80 over something and she walked out. Alice followed her out of the room and asked for his blood pressure reading. She mumbled and checked told Alice his blood pressure was 80/45. Alice told the aid that she wanted to speak to the head nurse immediately and wanted to know why that the aid did not notify the nurse immediately after a critically low blood pressure reading. She expressed her concerns to the nurse that if his blood pressure was that low, the nurse should have been notified and a ambulance called.
The head nurse came in and checked his blood pressure again. She had no excuse why the aid did not contact her immediately or notify her of it being so low. The nurse checked the blood pressure again and told us it was 106/62. We then questioned why at 6:30-6:45 his 5:00 wound dressing had not been completed. The nurse went to get the supplies to do it. She brought in the bandages, and pulled gloves out of her scrub pocket and laid them on his dresser to do the change. I never once saw her wash or sterilize her hands.
I had asked the nurse, if she planned on using sterile gloves to do the wound change. She said no, that they were not needed, it was procedure to use regular latex gloves and that they didn't have sterile gloves at the facility. I told the nurse that this was unacceptable and with the severity of the wound, sterile gloves were required to prevent infection. Not only were the gloves she planned on using NOT sterile, they had been contaminated from her dirty hands, her scrub pockets and now the dirty dresser and those gloves would be touching the gauze that would be placed into his back next to his spine and close to his vital organs. They are in no way practicing safe wound dressing procedures to prevent infection. I told her that she would not be touching him with those gloves and demanded that either they use sterile gloves or he would be pulled from the facility. We even started calling nearby pharmacies in order to purchase sterile gloves to be used on his wound dressing. The nurse went and pulled sterile gloves from a catheter kit and complete his wound change.
Around 5AM on 4/24/2016 Steve became ill and had feculent vomiting. Instead of calling for emergency medical services, the staff at Columbus Health had his bed cleaned, changed his clothes and instructed him to get back into bed. Steve insisted that a squad be called. The assistant hesitated and told him she would have to check with the nurse. After Steve demanded a ambulance, he was transferred to Doctors West Hospital and admitted into the ICU because his blood pressure was dangerously low and they feared internal bleeding and a bowel obstruction.
Emergency contacts and next of kin where never notified of his transfer to the hospital. When Alice Dotson stopped by the facility later in the evening, staff could not explain to us why procedure was broken and his family was not notified. There response was that the staff from that morning was no longer there, so they would have to ask them.
Other noteworthy but less urgent complaints we had with this facility include:
* Some residents to appear not to have been bathed in quite some time. We noticed residents walking around with very dirty/greasy hair.
* Hallways were cluttered with various carts, medical equipment and debris
* When going to the vending area in the dining hall, the kitchen was disgusting and it complete disarray. It did not appear that it could pass a health inspection. Even though dinner service was over, the dining area was not cleaned and the kitchen was in complete disarray. The coffee urn was set out for residents, and it looked like it had not been cleaned in a very long time. I understand that this is a commercial facility, but I expect a level of cleanliness when preparing meals. I would not feel comfortable eating anything that came out of that kitchen.
Summary of complaints:
1) Blood Pressure was read incorrectly and/or low blood pressure readings where not immediately reported the nurse and checked out.
Staff was not trained properly in taking blood pressure and realizing when low blood pressure is a medical emergency.
This happened TWICE during his 48 hour stay. One of these drops required ICU hospitalization.
2) Wound dressings not completed in the doctor required 12 hour time frame; bandage was not changed even after it had soaked
through clothing.
3) Unsafe wound dressing procedures increasing infection and contamination risks. Nurse attempted to use contaminated gloves that had been in her pocket and laid directly on the table. Did not see nurse wash her hands prior to handling.
4) Delay and or refusal to call for emergency medical services when resident was ill enough to require ICU hospitalization.
6) Failure to notify emergency contacts and/or next of kin in the has of emergency transfer to a hospital
7) Equipment/clutter in the halls
8) Some residents appear to not have been bathed in quite some time; witnessed very dirty/greasy hair on several residents
9) Cafeteria was not clean. The kitchen and dining room was left in disarray after meal time. Kitchen would not have passed a health inspection. Coffee urn has obviously not been washed in quite some time.
by Brian Bennett
xxx.xxx.253.10
April 26, 2016
