Infections in nursing homes
Posted by Christine Antonellis Norton of D'Amico & Pettinicchi, LLC on Oct 23, 2014 in Nursing Home Neglect
Infections in nursing homes are associated with high rates of morbidity and mortality, frequent hospitalizations, pain, a rapid decline in cognitive and physical functioning, and often death. As such, nursing homes are required to have a heightened awareness for preventing infections, diagnosing infections, and treating infections.
Infection in the nursing home setting is often an avoidable consequence of untrained nurse aide staff or overworked nursing staff. Two of the most common sites for infections in a nursing home setting are urinary tract infections (in both men and women) and pneumonia. Urinary tract infections can arise anytime but are often associated with dehydration, inadequate toileting schedules, immobility, or urinary and/or bowel incontinence. Pneumonia is associated with the aspiration of food or fluids due to an inappropriate diet or the failure to properly supervise meal times. Other sites for infection include the salivary gland(s), and pressure sores. Salivary gland infections are common with dehydration or poor oral hygiene. Pressure sores are considered a "never event" which occur in the setting of the failure to properly relieve pressure on a resident's skin by either frequently turning a resident in bed, appropriately ambulating a resident, or utilizing some other pressure relieving devices such as specialized mattresses or boots. These sores are open wounds that are then vulnerable to infection which can lead to sepsis or a severe bone infection (osteomyelitis).
Oftentimes these infections are overlooked because the geriatric population does not present with the typical signs and symptoms of an infection. Nurse aides and overworked nursing staff often fail to recognize the atypical presentation until it is too late. Fever, typically defined as greater than 100.4 degrees, is absent in more than 50% of nursing home patients with serious infection. The 2008 updated guidelines from the Infectious Diseases Society of America suggests defining a fever in patients in long term care facilities as either a single oral temperature of greater than 100 degrees, or repeated oral temperatures greater than 99 degrees, or, importantly, an increase in temperature of greater than 2 degrees over baseline. This is important because the elderly population often has a lower than typical baseline temperature. The nursing home population typically has some level of dementia that compromises the ability to communicate symptoms clearly. As such, the presence or absence of a pain complaint is not a reliable indicator of the presence or absence of an infection. Nursing staff should be able to identify alternative signs of pain like facial grimacing, depression, weight loss, picking at skin, withdrawal, or avoidance of certain tasks or movements. Infection should be suspected in nursing home residents who exhibit new or increasing confusion or delirium (defined as an acute change from baseline dementia), new or increasing incontinence, deteriorating mobility, decreased food intake, decreased fluid intake, and changes in behavior (lethargy, somnolence, agitation or aggression). A nursing home is required to make sure a resident receives complete and appropriate assessments by a licensed registered nurse whenever these changes in condition occur and the nurse must notify the attending physician and family for direction or further testing including blood testing or x-rays.
If caught early enough an infection in a nursing home can be treated effectively while the resident remains in the nursing home setting, thereby avoiding a disorienting trip to the emergency department or an inpatient admission to a hospital. Appropriate antibiotics with supportive measures including fluids and oxygen may be all that is necessary to treat an infection. Many times though, an infection is not caught until it is too late, causing unnecessary pain and suffering and the loss of a loved one.