Genital pressure ulcers lead to Immediate Jeopardy citation, admissions halt

Tennessee has suspended new admissions of residents to a Limestone nursing home following allegations of neglect that led to pressure ulcers for at least four residents, including severe genital wounds.

In addition to a civil monetary penalty of $4,000, the health department appointed a monitor to review the operations of the 63-bed John M. Reed Health and Rehabilitation facility, the Knoxville News-Journal reported. Calls to Reed seeking comment were not returned by press time.

In one case, the surveyors said a man arrived at the facility with a urinary catheter. The resident developed pressure ulcers on his penis, which became worse when there was no antibiotic prescribed. He developed a drug-resistant staph infection and sepsis, and lost 4 centimeters of tissue on his penis. Other residents also were found sitting in waste-laden undergarments or clothing, the paper reported.

The nursing home, which is owned by New Beginnings Care, was understaffed, specifically in the area of certified nursing assistants, surveyors said.

Other allegations included lack of fire alarm system batteries, lack of proper infection control when cleaning wounds, and failure to notify a doctor or family after a resident with dementia eloped. The state began investigating complaints in October and surveyed in November, then made the announcement on admission suspension Dec. 3.