East Carolina Health: Stage 4 Pressure Sore Hidden - NC

Resident 8 at East Carolina Health and Rehabilitation Center received a one-time dressing change order for her sacrum on August 10. But no one contacted the facility's wound physician again until August 20, when the doctor made a routine visit and discovered the severe pressure sore herself.

The wound physician found a dressing dated August 12 still attached to the resident's sacrum eight days later. The Stage 4 pressure sore measured 2.3 cm by 2 cm by 1 cm deep, with 90 percent dead tissue covering the wound bed and only 10 percent healthy tissue attempting to heal.

"The area had not been known to exist by her or the Wound Care Nurse until that date," the wound physician documented about the August 20 discovery.

Nurse 2 had worked a double shift on August 10, from 7 AM to 11 PM, and noted in the shift change report that the resident had a sacral wound. The information passed to Nurse 3, who started caring for Resident 8 the next morning.

But Nurse 3 could not recall what she did when told about the sacral wound during the August 11 shift change. She told inspectors she would have passed the information to the wound care nurse.

The wound care nurse had been on vacation from August 11 to August 15. She told inspectors she didn't know about the pressure sore until August 20 and didn't recall seeing an old dressing on the resident's sacrum when the wound was discovered.

During those 10 days, no one documented contacting the physician about the pressure sore.

The wound physician told inspectors the facility could contact her at any time to obtain treatment orders. She was not aware of the resident's sacral pressure sore until her August 20 visit.

When the wound physician finally saw Resident 8 on August 20, she also discovered a deep tissue injury on the resident's right heel measuring 5.1 by 4.7 centimeters. The heel wound appeared to be the size of a baby food jar lid with both pink and black tissue visible.

The Director of Nursing told inspectors that nurses should contact the physician about new pressure sores and obtain orders to treat them. But this didn't happen for Resident 8.

The resident had been declining recently, according to the nursing director. She used to eat meals and participate in facility activities but had stopped both. Resident 8 also had underlying medical problems and recent gynecological bleeding that remained undiagnosed.

By September 8, a nurse practitioner entered an order for a hospice referral.

The facility's medical director, who served as Resident 8's primary physician, told inspectors she had not been aware of communication problems about wound care. She noted that if the resident was appropriate for hospice services and diabetic, the wounds might not heal regardless of treatment.

When inspectors observed wound care on September 10, the sacral pressure sore appeared pink and healing. The wound physician reported the sacral wound had improved and said she didn't think the delayed notification and treatment orders resulted in a negative outcome for the resident.

But the 10-day gap in physician notification violated federal requirements for nursing homes to ensure residents receive proper wound care and medical attention when conditions change.

The inspection found that some residents were affected by the facility's failure to notify physicians promptly about wound conditions, though inspectors determined the violation caused minimal harm or potential for actual harm.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for East Carolina Health and Rehabilitation Center from 2025-09-11 including all violations, facility responses, and corrective action plans.

Additional Resources

• View all inspection reports for East Carolina Health and Rehabilitation Center
• Browse all NC nursing home inspections