Why do nurses refuse to admit there is a pressure sore that developed in house?

I would like to discuss the use of the term 'nurses' to describe the staff involved in this discussion of pressure sores too. Too many in our society do not understand the differences in kinds of 'nurses'. In Arizona, most skilled facilities, assisted living and memory care units have very few or NO registered nurses, who are the most highly skilled nurses....most of whom these days have a college education and are highly skilled in assessment skills and ability to think out of the box and realize that care needs are based on individual situations without a clear answer or routine that fits everyone. In AZ, if a facility does hire RNs, they are either the ones who keep all the paperwork in order, while supervising others, or they are the one in the front office, the 'director' of nursing, who is responsible for organizing all the direct care givers. Then there are LPNs, who many also call nurses...but they have had generally a year of school and are only slightly more educated than the aides....in that they can give medications, monitor IVs, give shots and do more things like dressing changes that require a bit more training. They do not have the critical assessment skills to be PLANNING care and changing plans based on individual's needs. In general, in Arizona, they are the ones supervising the aides and other caregivers, while giving meds to residents/patients. The general public typically does not understand this difference, and because I am a retired RN, I see red when I hear people referring to EVERYONE as 'the nurse'.....they think all the workers in the doctor's office are 'nurses' or are RNs. My mother, when referring to the caregivers in my Dad's facility, calls them all 'nurses'. His facility has ONE LPN on each shift that supervises staff in 5 different cottage...each can have up to 3 caregivers working and up to 14 residents each. There are NO RNs. Even the Program Director, who supervises all the direct care staff and handles staffing and hiring and training etc, is an LPN. The Executive Director of the entire facility is a RETIRED RN and the only RN in the entire place. So, there really are no direct caregivers, who really have the education and training to be making any clear assessment about someone's 'bed sore' at all. An LPN can say, "YES....it's not normal" and suggest that routine plans be made like turning every 2 hours. But they cannot recommend changing treatments or what medicine to apply nor will then generally be able to consider all else about that person's medical history and then be able to say....OH, she needs to be turned hourly, or she needs to get a whirlpool bath every day or we should add heat or this ointment or that or leave it exposed to air and not covered...and so much more. They will say, "We have to show this to the doctor the next time the doctor comes' for example. They just do not have the training to do much except observe and document or report what they see to someone else. These different types of nurses are licensed by the state to be able to do very specific things on their own. Typically, the aids work under the supervision of an LPN or an RN. LPNs can work alone in specific types of facilities. for example they can work alone in AL or Mem Care, but not in nursing homes. There has to be at least one RN on in a skilled nursing facility...but not necessarily at the bedside doing direct care. In a hospital, the LPN must work under supervision of an RN and both must be at the bedside. In a doctor's office, an LPN must work under supervision of a doctor if there are no RNs hired. And, just for the record, there are generally NO RNs or LPNs in doctor's offices anymore. They are all medical techs. And yes, the doctor can teach them to give a shot or medication....but not IV meds. Only an RN can start IVs or give IV meds, other than the physician. I so wish that more people would look at the person who is going to 'do something' to them, and ask directly 'What is your title and what is your education?' In the first big facility my Dad was in we were told the director of the Memory Care unit was a 'nurse'....and after we had problems communicating with her, discovered that she was not even an LPN! Then we had more issues and asked to talk to the nurse supervisor....that person came over, and said she was an LPN....but my daughter and I...both RNs...could not communicate with her at a basic level that an LPN should understand, so my daughter asked her the question about training and education. Turned out she HAD BEEN an LPN many years earlier; was in a job that required her to be an LPN but was no longer licensed as an LPN. She didn't understand a thing we were trying to discuss and get answers too....but would NOT admit she was not a licensed LPN. We reported that to the state. it was wrong. And everyone who gives meds in the memory care system in AZ, is only an aide who has gone through some training in how to give meds. They do not even have the ability to decide to give my Dad a Tylenol that is ordered if he has a headache, because they are not allowed to. So if Dad says his head hurts, they have to call the LPN to come and she has to talk to him and she has to tell the aide giving meds to give him a Tylenol. That means that typically nothing extra gets given unless family is there to push buttons about it because the aids/caregivers, do not like to call the LPN into the cottage when she is supervising so many and is in between 5 different cottages. So hope this helps everyone understand the differences in abilities of the types of caregivers you see in health care. And then explain why some of these strange things happen like 2 people talking about a bed sore and not wanting to call it what it is.....

I think a lot of the problems lie with staff being asigned to different patients every day. they never get to know individual patients and there is no supervisor going round who knows everybody. As you say too many under trained staff.

They all deny it. The problem lies at under trained not caring staff. Very few cna,stna,hha, whatever they are being called nowdays, actually do their job and care, in my opinion LPNs should replace all cna, stna, hha direct care positons they have real training. I did hear some hospitals screen all prospective caregivers ( doctors, nurses, pt ,ot, ect.)for how empathic they are toward people and wont hire people they think arent caring enough. Thats why they are the top hospitals

I am so glad we (my dad and I) decided to keep my mom home and care for her there. We love her and do the best we can with help from hospice. Yes she has bed sores but we are taking care of her all day long. She is dying and there is nothing we can do about that she is almost 92, but we love her and bathe her and move her and talk to her and feed her. At least she is not being ignored at a facility that is only interested in the money.

Dear Veronica,

Thank you very much for responding to my post and thank you for the hug. Yes, this was my first death. I have experienced death in the past of friends and family members but I was not the caregiver and did not experience the transition to end of life. I will always remember this particular person. I actually learned so much from her during the time I took care of her even during the transition and I thanked her for allowing me to help her even when I knew she had no hearing left. You make sense in that I am grieving though I did not think I was grieving. I will let myself feel the way I feel and perhaps my new assignment will help me move forward. I start this Thursday. I feel so much better now having read your response and having answers to my questions from you as to what I am feeling. I think I was so used to going to my little lady's home each day and seeing her husband, her friends, her doggies and caring for her that it became such a huge part of my life and perhaps I was even in some denial about her life coming to an end. But yes, you are right in that professionally I must move forward and file the feelings away in my inventory of experience. The way you said this makes sense to me. File it away and move onward. Maybe I will talk to my husband one of these days about this experience but right now it just feels so intimate and personal and that is why I turned to this group as I knew I would be able to write down my feelings with other professionals and get the help I need. Thank you Veronica. Sending a big hug back to you:) I hope we can stay in touch. Sincerely, Elizabeth

elle3000, hugs to you for caring so much for your patient. You made a great deal of difference in her final time on this earth.
What you are now experiencing is probably simply grief.
Was this your first death?
Everyone experiences grief differently but look up stages of grief and you will find it takes a particular course and every stage has to be experienced. It is different for everyone and each stage does not have a predetermined length.
Once you begin your next assignment it will be easier to move forward. Every caregiver feels a sense of loss when they loose a patient but professionally you have to move ahead and file these feelings away in your inventory of experience. Some patients you will remember for ever others not so much. Now you have written about your feelings it will be easier to talk to your husband.

Hello. I wonder if anyone can help me to understand the feelings I am experiencing as a CPC who just lost a patient after taking care of her for two months. I adored this sweet lady and did my best to maintain her dignity and integrity right to the end of life. I went through the transition period with her. I sat by her for 24 hours straight when she was nearing the end. I left to go home and take care of a few things and then returned for a few hours until a family friend came over to sit with her. I advised my agency that I was going home. Within four hours of my leaving my little lady passed away. During the 24 hours of sitting with her my mind was constantly working with deep thoughts about life, God, death, suffering and so forth. It was like a "spiritual marathon" and though I was exhausted I could not stop my mind from questioning life and death. I could not bring myself to attend the services. My issue is that I am not depressed, I am not sad as she is now at peace but I feel very strange and cannot fully express my feelings to anyone. I don't feel any guilt as I provided her with the best care possible. I have had one bad dream since her death that shook me up a bit. I don't feel self pity or anger that I was not there with her when she passed away. When she was coherent we would talk quietly and there were times we shared some tears but I made sure she knew that I was honored to have been part of her life and she told me that we were friends. It meant a lot to me. I feel like I have been in a war zone but I don't have PTSD. I can't explain these feelings as I cannot pinpoint exactly what I feel. I continue with my daily activities but not with as much enthusiasm. My husband is a kind man but I cannot discuss my feelings with him as I would not know where to start. I don't feel like talking about all of this to friends or family or to my Agency. I am already lined up for another assignment which may be a blessing in disguise. Can anyone here help me to understand why my world seems so "blank" right now and why I can hardly muster the energy to smile. Thank you in advance for any suggestions or shared experiences.

Lots of things can cause skin irritations, but when one is in a long term care facility pressure sores come to mind. Many facilities do not want to document a decubitus, it looks better to have a record of none. If a facility has a pattern of skin breakdown they can receive a fine. Some people need to be turned and repositioned every hour instead of every 2 hrs. No matter how you look at it, a pressure sore is a pressure sore and many times it caused from lack of care. I agree that often the aids are blamed for things that happen, but it is also staff that cares about their residents make the residents life worthwhile. Don't stop caring.

Why do nurses (and others) refuse to admit there is a pressure sore (or other, similar problem)? Blame.

When you live - as we all do - in a culture where people focus far too much on who is to blame for a problem, rather than on dealing with the problem, everyone spends too much time dodging the blame. Thereby they also dodge the issue. It is bad news for everyone.

It also makes it very hard to ask questions or make observations without causing an automatic, defensive reaction: this leads to poor communication, which leads to poor care.

In a neutral world, you would be able to state calmly "this patient has developed a pressure sore" and all attention would be focused on getting it healed and attempting to prevent further ones developing - always bearing in mind, of course, that in very frail, ill patients it isn't even necessarily possible to achieve that. In our sad world, as you have so clearly described, half of the nurses' time and expertise is wasted on polishing the patient record. It is infuriating, it is wrong, it is detrimental to patient welfare.

Much cleverer people than me are doing their best to sort it out, with some success in some hospitals for example, and that is the most hopeful aspect I can see of the whole sorry mess.

Love of Money is root of all Evil.

Pressure sores develop when bacteria starts eating the flesh underneath the skin, then going through five layers of epidermis, then breaking open the skin developing a tear and oozing out with pus which is infected bacteria. You can have pressure sores on the arms from people grabbing onto a frail person and tearing the skin. They both are breaks in the skin where bacteria can grow.

Skilled nursing facilities are NOTORIOUSLY understaffed. The priority is maximum profit for the owners & dangerous staffing levels, practically no "extras" for the residents (like A&D ointment, television, laundry, etc.) It is not unusual for an RN to have a patient load of 40+ patients, and for an LPN to be responsible for passing meds to 40-60 patients in a day. Forget about the CNA's----they have so many patients to bathe, feed, change Depends, turn & position, get into wheelchairs & back into bed, etc. that they're lucky they can walk out the door at the end of their shift. Most long term care facilities are privately owned, & so the priority is profit, not quality care. Sure, the brochures & websites that show elderly people will big smiles on their faces & a nurse sitting next to them holding their hand are greatly exaggerated. A nurse doesn't have time to go to the bathroom, so forget about holding anybody's hand. But pretty, glossy, fancy brochures is great marketing---nobody would go to a place that put a picture of a huge bedsore on the front cover of it's brochure.

Bedsores that develop in a long term care facility are a MAJOR big deal----they are reportable to the state & then the state will come & do an inspection of the facility. They'll find problems & cite the facility for the problems. The facility has a set amount of time to fix the problems or else they lose accreditation. Most places put on a big show when they know they are being audited & inspected---they put extra nurses & CNA's on duty, they fudge the staffing sheets to make it look like there are more working than there really were, staff gets told to be extra nice & know where the fire escapes are, & everybody acts like they are so vigilant. As soon as the inspection is over, everything goes back to the way it was. There is little oversight of LTC facilities. The state is supposed to oversee them, but the truth is that there are so many LTC places that it is impossible to keep track of them all.

My mom lives at home with me and I do have a lady who stays with her during the day so I can go to work. My mom is very thin and developed a pressure sore on her bony little hip. She sleeps on her left side, and no matter how she starts out at night always manages to turn to her left.
We finally got it healed, but it was an ordeal as she always managed to peel off the bandaid and land back on her left side.
I guess what I'm saying is that sometimes no matter what you do or how hard you try those pressure sores can still pop up.
Calling a pressure sore a skin tear, though, is absurd.

Well as a nurse having worked in the hospital and nursing home setting, I will tell you I never denied a decubitus (pressure sore) as what it was. Turning every two hours is standard care, however, when sores get very bad, at some point in time this is the body's way of saying the tissue is very compromised. No amount of turning and nursing care will help if this person is dying. Nurses and doctors are not Gods. We cannot prevent sores. If you have concerns, take them to the director of nursing at your work and discuss your concerns. Telling us will do no good for that patient. If the nurses are too busy to turn, ask them while you are perhaps bathing or changing sheets if you can reposition, if you are able. Do not hurt yourself. And if you are very unhappy with your work environment, work somewhere else or improve your education so you will be more in charge of patient care. Being part of the solution is much better than complaining. You have the ability to improve your life. Merry Christmas!

Having worked as a CNA for years, in a number of facilities, I can tell you this is nothing new. Some of the abuses I have seen are shocking. I am no longer working as a CNA for those reasons, as well as the low pay and understaffing. I now look after my 94 year old mom and 87 year old dad, who live in an assisted living facility. Now I get to see the corporate abuse as well. Constant overcharges in the billing, a refusal by the director to itemize the bill so that I can have an idea what the extra charges are for, medication theft, etc. First and foremost, assisted living and skilled nursing facilities are a business, run like any other. As a CNA, you are required to keep your mouth shut if you want to keep your job. My recommendation is to work in Adult Family Home where you only have six people to care for. There is more time to give adequate care, and the families are more often involved as well. That was my experience, anyway.

Veronica91. You are a rare jewel. Thanks. Not like the professionals I have run across in this area. Three years ago I was a professional artist and art teacher and believed the best in people. Thought they did their best. Thought they though like you. I am not angry. I am amazed and saddened at the care in facilities. The hard court press to "sell" the facility. The glossy brochures of residents playing miniature golf. Really! Car sales. We have one decent facility in this area and it has a two year waiting list. Like the Dr. in the hospital told me...the rest are holding tanks. Maybe it's time to move from this dying area. Thanks for your long post. You must have been a fantastic nurse!

DaveIMF. Yep. How about ALL decisions fall into CYA. Thanks for the simple answer. Easier and smarter than dwelling in blah blah blah. Thanks

passivesambo. You are so right and so wrong in your observations about this patient's pressure sore and that is probably why no one else has replied to this after three days. They don't want to touch it with a ten foot pole. My first reaction to your post I will admit was anger. But anger is bad for my blood pressure which is already too high.
On calmer reflection.
There are many reasons why patients develope pressure sores and they are all related to the blood supply to an area. Some are definitely due to neglect and others due to circumstances. Have you ever got a sore on your heel from improperly fitting shoes or a blister on your hand after using things like scissors or a screwdriver? these are all pressure sores and if you continue to do whatever caused the problem they will get worse, bleed and may become infected.
This patient is clearly seriously ill and although you don't say likely a patient in a nursing home. She is comming to the end of her life and all her vital systems are slowly shutting down which means her blood is not pumping round her body as effectively as yours is. blood carries oxygen and nutrients to all parts of our bodies. Her bottom is not recieving enough and in her weakened state there will be skin break downs in areas where a lot of pressure is applied. I can not judge if she is being turned or not but assuming she is it is likely she would also be at risk for sores on both hips as well and maybe elbows and heels, ears, cheeks, nose and anywhere else pressure is applied.
There is failure to provide proper care in residential facilities as everywhere else. i don't know if this is the case where you work. Nurses have to be very careful in the notes they make in a patients chart because of the ever real fear of lawsuites. That is fact not defense of what you saw.
Now what you saw was clearly a pressure sore. I don't doubt your word. the dressing had to be so large so it could be taped to healthy skin and not have the tape cause further damage. The discoloration you observed around the open area was probably not caused by the wipes you used to clean, if it was you would not be allowed to use them on anybody. The purpleish skin was further extension of the sore and will eventually open up too, it has to because it is dead tissue and it has to be allowed to slough off for healthy tissue to regenerate underneath. red bleeding areas are actually good news. it indicates that area is healthy and has a good blood supply. In very severecases the dead tissue may be surgically removed.
You mentioned this patient is not eating which indicates she may be close to the end of life. if you ever work in the home with dying patients you will be appaled at what you see when skelital patients cling to life for some reason and despite the loving care they are recieving their bodies will be covered in sores. the caregivers feel so much guilt and second guess many decisions but the experienced nurse is able to reassure them they have given the best of care and even if they had done the turning every five minutes the outcome would not have changed.
I can not judge the treatment the nurses you observed were giving. I was not there and have not read the orders for this patient.
You are a CNA with minimal training and I have no idea how much experience, and clearly want the best for your patients so do the best job you can in what you are trained for and the day to day responsibilities and remember to report anything you may observe so that the RN.s LPN.s whoever is ultimately responsible for the patient's care that day can alert the Dr. You have done your part. No harm in asking questions but don't accuse, that makes people defensive and you won't learn that way. if you plan to continue further in a nursing career everything you learn as a CNA will be invaluable. There is a huge amount of information on everything from basic nursing care to the interaction of drugs on the internet. Not only will it help you become a first class CNA but greatly assist in any future training you seek. I trained as a RN almost 60 years ago in the UK and in those days it was more like an aprenticeship where we started out doing CNA type things and a lot of cleaning because nothing was disposable, but were ecouraged to watch anything going on that our superiors were participating in. I know it is a different world but I have been retired six years and still keep up my research and interest though a forum like this. Good luck to you in the future. Keep questioning but don't jump to hasty conclusions learn a lot and when you are in charge make sure everything is done right.

Such decisions fall into the category of CYA

Recently removed my Mother from ALZ two week respite facility for SAME reason. Also theft. Soant hidden issues. All denied. She was always soaking wet. Diaper not changed unless I did it. I was there day and night. Staff so nice toy face. Facility a chain. Supposedly high end. New here sine April. Still only 7 patients. We now have our wound center treating her for the bedsore. She is home with me. The ALZ facility told me to keep it covered with A&D ointment. Called me and told me to buy some and bring it to mom. Common sense told me something was wrong with that. They insisted. Up until that point it was a slightly pink pressure sore. I had it under control. Once she went there it became soaked in urine unless I showed up and cleaned her. One time I took her diaper up to the nurse to show her it's weight in urine. This night nurse was getting ready to go home and said that was impossible. That she had just changed her. Yes, some places really avoid the truth. Easy to do. Keeps their statistics looking good. Criminal. I took on out. She is home. Sore almost gone. Good luck. Keep your eye on your loved ones in a facility. There ate good nurses and bad nurses. The bad ones often know how to play the game and hide the truth. The good nurses are aware of this but can't do anything about it. Understaffed and overworked. The $$profits are shocking. Good care or bad care the owner is hauling it in.