Staff at New Mark Rehab and Healthcare Center discovered the problem on September 19 when they noticed Resident #2's wound vacuum "did not look right." But when Licensed Practical Nurse B tried to find documentation of when the dressing had last been changed, none existed.
The only record LPN B could locate showed the wound vacuum was in place on September 10. No orders existed for dressing changes.
When LPN B attempted to remove the dressing using saline to soak it loose, the third sponge was "severely adhered" to the resident's wound. One area began bleeding significantly as the nurse worked to free the stuck material.
"He/She cut away the old dressing, applied thick padding, and wrapped the leg with gauze, as the wound was bleeding significantly," the inspection report states. The wound bled through the thick dressing before emergency medical services arrived.
The resident required hospitalization.
A physician assistant who responded to the emergency said the amount of bleeding was unexpected for a routine dressing change. "He/She would not expect a dressing change to cause that kind of bleeding," the PA told inspectors. "He/She would not expect a dressing to be stuck that badly if it was changed regularly."
Nurse Practitioner A, the resident's primary care provider, had never seen a wound vacuum dressing adhere to a wound. The facility called to notify the practitioner only after the bleeding incident occurred.
Wound vacuum dressings typically require changing twice weekly or more frequently if drainage is excessive, according to LPN B. The technology uses controlled suction to promote healing, but the dressings must be maintained properly to prevent complications.
The facility had no wound care specialist on staff when the incident occurred. LPN B told inspectors he was unaware who would order wound care supplies in the absence of a wound nurse.
Administrator interviews revealed systemic confusion about wound care protocols. The administrator acknowledged staff should have obtained orders from the hospital where the resident had been treated or called the physician directly. No such orders existed for Resident #2's wound vacuum dressing changes.
"He/She was aware there were no orders for the dressing change after the resident was sent to the hospital," the administrator admitted to inspectors.
The incident represents what federal inspectors classified as "actual harm" to the resident. The inspection was triggered by a complaint filed with state health authorities.
The case illustrates the risks when nursing homes lack clear protocols for specialized wound care equipment. Wound vacuum therapy, while effective for promoting healing of complex wounds, requires trained staff and consistent monitoring to prevent complications.
LPN B's decision to call emergency services likely prevented more serious injury. The nurse recognized the severity of the bleeding and took immediate action to control it before transport.
But the fundamental problem remained unaddressed: staff operated wound care equipment for more than a week without physician orders or clear protocols for maintenance. The resident paid the price when the neglected dressing became embedded in healing tissue.
The facility's administrator acknowledged the breakdown in communication and oversight that led to the emergency. Yet even after the incident, basic questions about wound care ordering and supervision remained unresolved.
Resident #2's experience demonstrates how quickly routine medical care can become dangerous when facilities lack proper protocols and oversight for specialized equipment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New Mark Rehab and Healthcare Center from 2025-09-26 including all violations, facility responses, and corrective action plans.
Additional Resources
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