HAZLETON, PA - Federal inspectors found that The Pavilion at St Luke Village failed to provide appropriate care for a pressure ulcer, resulting in the wound's deterioration and the development of a serious bone infection that required hospitalization.
Critical Pressure Ulcer Care Failures
During a July 19, 2024 inspection, federal surveyors documented severe deficiencies in wound care management at The Pavilion at St Luke Village. The most serious violation involved a resident who developed osteomyelitis, a bone infection, after the facility failed to implement recommended treatments for a pressure ulcer on the resident's right heel.
The resident, identified as Resident 94, was admitted to the facility with an existing 3 cm x 3 cm unstageable pressure wound to the right heel that appeared necrotic, containing dead black tissue. However, inspection records revealed that nursing staff failed to conduct comprehensive wound assessments or implement critical pressure-relieving interventions.
According to medical standards established by the Agency for Healthcare Research & Quality, effective pressure ulcer prevention requires three essential components: comprehensive skin assessment, standardized risk evaluation, and implementation of targeted interventions. The facility's failures violated these fundamental principles of wound care.
Inadequate Assessment and Treatment Protocol
The inspection revealed significant gaps in the facility's wound assessment procedures. When the resident was admitted, nursing staff documented only basic measurements of the pressure wound but failed to record critical details including drainage, odor, wound edges, or the appearance of surrounding tissue. This incomplete assessment continued throughout the resident's stay.
A wound consultant who evaluated the resident on July 10, 2024, found that the pressure sore had increased dramatically in size, measuring 3 cm x 7 cm x 0.5 cm, with a wound base that was 100 percent eschar (dead tissue). The consultant noted that the wound appeared "boggy" - soft and spongy - with a foul odor, and recommended immediate implementation of a repositioning schedule and the use of Prevalon boots to reduce pressure on the heel.
However, inspection records showed no documented evidence that the facility implemented these critical recommendations. The failure to follow professional wound care guidance directly contributed to the wound's continued deterioration.
Development of Serious Bone Infection
The consequences of inadequate wound care became evident when the resident developed osteomyelitis. On July 11, 2024, an X-ray revealed calcaneus erosion consistent with bone infection caused by bacteria. This represented a significant escalation from a manageable pressure ulcer to a serious medical condition requiring intensive antibiotic treatment.
Osteomyelitis occurs when bacteria invade bone tissue, typically through an overlying wound. In nursing home residents, this condition most commonly develops when pressure ulcers are not properly managed, allowing bacteria to penetrate deeper tissues. The infection can spread rapidly and may become life-threatening if not treated promptly with intravenous antibiotics.
The facility's delayed response compounded the problem. After the bone infection was identified on July 11, the facility waited five days before notifying the physician on July 16. Hospital records from July 17 indicated that the resident required immediate intravenous antibiotics and extensive wound debridement.
Medical Implications of Wound Care Failures
Pressure ulcers are preventable injuries that occur when sustained pressure restricts blood flow to skin and underlying tissues. Proper management requires regular repositioning, pressure-relieving devices, and meticulous wound assessment to identify early signs of deterioration.
The failure to implement repositioning schedules and pressure-relieving devices like Prevalon boots represents a fundamental breach of accepted wound care standards. These interventions are considered basic elements of pressure ulcer treatment because they address the underlying cause - sustained pressure that prevents adequate blood circulation.
When pressure ulcers progress to involve underlying bone, as occurred in this case, treatment becomes significantly more complex. Hospital records noted that "the underlying bone infection would not resolve even with months of IV antibiotics" and that "without debridement of dead bone the chances to cure the osteomyelitis are nil." This prognosis illustrates the serious long-term consequences of inadequate initial wound care.
Medication Administration Failures
The inspection also identified failures in medication administration that could compromise resident safety. Surveyors found that Resident 148, who was admitted with a PICC line for intravenous antibiotic treatment of a septic knee infection, did not receive prescribed doses of Daptomycin antibiotic on July 12, 13, and 14, 2024.
Daptomycin is a specialized antibiotic used to treat serious bacterial infections. Missing consecutive doses can reduce the medication's effectiveness and potentially contribute to antibiotic resistance. The facility's policy requires medications to be administered within one hour of their prescribed time and mandates notification of physicians when doses are missed.
The Director of Nursing confirmed that the facility failed to administer the three daily doses and did not notify the attending physician of the missed medications, representing violations of both facility policy and standard medical practice.
Inadequate Bowel and Bladder Management
Inspectors also documented deficiencies in continence care for Resident 38, who experienced declining bowel function during her stay. The resident reported waiting more than 15 minutes for staff to respond to call bells for toileting assistance, resulting in incontinence episodes.
The facility's policy requires comprehensive bowel and bladder evaluations upon admission and quarterly assessments, with individualized continence management programs based on evaluation results. However, no evidence existed that such evaluations were completed for this resident, despite documented decline in bowel function.
During an interview, Resident 38 stated that "nursing staff often take a long time to answer her call bell and provide assistance with toileting when needed" and described having an accident after waiting more than 15 minutes for assistance.
Additional Issues Identified
The inspection revealed other concerning patterns including incomplete wound documentation, failure to follow consultant recommendations, delayed physician notifications, and inadequate implementation of facility policies. These issues suggest systemic problems with clinical oversight and staff training rather than isolated incidents.
The facility's administrator acknowledged during interviews that the facility could not provide evidence of timely implementation of measures necessary to promote pressure ulcer healing and confirmed failures in continence evaluation procedures.
Federal regulations require nursing homes to provide residents with the highest practicable level of functioning and to prevent avoidable decline in physical condition. The violations documented at The Pavilion at St Luke Village represent serious departures from these standards that directly impacted resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pavilion At St Luke Village, The from 2024-07-19 including all violations, facility responses, and corrective action plans.
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