SAINT LOUIS, MO - Federal inspectors documented serious breakdowns in wound care protocols at Hillside Manor Healthcare and Rehab Center after a patient discharged from the hospital with a pressure injury developed two additional wounds due to inadequate follow-up treatment.
Breakdown in Post-Hospitalization Care
The March 2025 inspection at the 145-bed facility revealed that staff failed to implement proper wound care procedures for a resident who returned from hospitalization with a documented pressure injury to the tailbone area. According to the inspection report, the facility did not maintain the treatment plan established during the hospital stay, resulting in deterioration of the existing wound and the formation of two new pressure injuries.
Pressure injuries, commonly known as bedsores, occur when sustained pressure restricts blood flow to the skin and underlying tissue. These wounds typically develop over bony areas like the tailbone, heels, and hips, particularly in patients with limited mobility. The tailbone region is especially vulnerable because patients who spend extended periods sitting or lying on their backs place constant pressure on this area.
The documented failures included multiple critical gaps in care coordination. Staff did not maintain accurate records of the wound's condition, failed to notify the attending physician about the worsening wounds, and did not obtain updated orders for wound care treatment. This lack of communication and documentation created a cascade of missed opportunities to intervene before additional injuries developed.
Medical Significance of Proper Wound Management
Pressure injuries progress through four stages, with early-stage wounds being relatively superficial but capable of advancing to deep tissue damage that extends to muscle and bone. Once a pressure injury develops, preventing its progression requires consistent, evidence-based interventions including regular repositioning, specialized support surfaces, proper nutrition, and meticulous wound care.
When a patient transfers from a hospital to a nursing facility with an existing pressure injury, continuity of care becomes essential. The receiving facility must review hospital discharge instructions, implement prescribed treatments without interruption, and monitor the wound closely for signs of improvement or deterioration. Any changes in wound appearance, size, or characteristics require prompt physician notification and potential modification of the treatment plan.
The development of two additional pressure injuries in this case indicates systemic failures in prevention protocols. Evidence-based guidelines recommend repositioning immobile patients at least every two hours, using pressure-redistributing surfaces, maintaining skin hygiene, and conducting regular skin assessments. The formation of new wounds suggests these preventive measures were not consistently implemented.
Compromised Wound Care Standards
The inspection also identified problems with basic wound care maintenance for another resident. Inspectors documented that staff failed to change saturated wound dressings in a timely manner, a fundamental aspect of wound management that directly impacts healing outcomes.
Wound dressings serve multiple critical functions: they protect the injury from contamination, maintain appropriate moisture levels, absorb drainage, and create an optimal environment for tissue regeneration. When dressings become saturated with drainage, they lose their protective and therapeutic properties. Saturated dressings can become breeding grounds for bacteria, increase the risk of infection, and cause maceration of surrounding healthy skin tissue.
Clinical standards specify that wound dressings should be changed according to manufacturer guidelines and the specific characteristics of the wound, typically ranging from daily to every three days depending on drainage levels. Allowing dressings to remain saturated violates basic infection control principles and compromises the healing process.
Regulatory Standards and Expectations
Federal regulations require nursing facilities to provide necessary treatment and services to promote healing, prevent complications, and achieve the highest practical level of functioning for each resident. These requirements include implementing physician-ordered treatments, maintaining accurate clinical records, and promptly addressing changes in condition.
The facility's own wound care policies, which inspectors referenced in their findings, outlined procedures that staff should have followed. The gap between written policies and actual practice represents a failure in quality assurance and staff oversight. Effective wound management programs require not only written protocols but also adequate staffing, ongoing education, supervision, and accountability systems.
Additional Issues Identified
Beyond the wound care violations, inspectors cited the facility for failures related to pain management, indicating concerns about providing appropriate relief for residents requiring such interventions. The inspection classified the level of harm as actual harm affecting a limited number of residents.
Implications for Patient Safety
These documented deficiencies raise concerns about care coordination, clinical oversight, and adherence to established medical protocols at the facility. Pressure injuries represent one of the most preventable complications in healthcare settings, yet they remain a persistent challenge requiring sustained attention and resources.
The Centers for Medicare & Medicaid Services conducts inspections in response to complaints and through routine surveys to ensure nursing facilities maintain compliance with federal health and safety standards. Facilities found out of compliance must submit correction plans and may face enforcement actions depending on the severity and scope of violations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillside Manor Healthcare and Rehab Center from 2025-03-20 including all violations, facility responses, and corrective action plans.
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