According to a recent article appearing online at the New Zealand Herald News website, an elderly woman in the care of a senior rest home succumbed to a bed sore infection.

The care facility was investigated and a report issued following the bed sore infection incident indicates that the rest home and registered nurse in charge are thought to be in violation of the Code of Health and Disability Services Consumer Rights.

The octogenarian was admitted to the elder respite care center 4 years ago in 2014. At some point, according to the report, she developed a pattern of blisters on both heels and a skin tear at the bottom of her spine.

Both wounds were suspected to be pressure sores—injuries to the soft epithelial and underlying tissues that affect the bedridden or those whose mobility is severely compromised.

Pressure or bed sores are most commonly located on bony areas that experience the direct weight of the body while lying down or sitting. These areas, according to the Mayo Clinic, include the back of the skull, scapula, elbows, sacrum, hip crests, ankles, and heels. There are over 200,000 bed sores diagnosed each year in the U.S., making them quite common.

Despite the frequency of diagnosis and the difficulty in treating them, it is rare to have a pressure sore turn into a full bed sore infection—as in this New Zealand case. Frequent changes of position to the patient, and regular wound cleaning and dressing can reduce the risk factors that would cause a wound to digress to a bed sore infection.

Upon review, records of the New Zealand octogenarian’s wounds and care were found to be contradictory, states the report. According to the New Zealand Herald News article, the patient’s condition was evaluated over a three-month period and regular descriptions of the wounds were entered into a progress report. The multiple descriptions did not line up with one another and an accurate picture of healing was not discernible in retrospect.

It was also undeterminable how many efforts by the clinical and nurse manager had been made to reach a local wound specialist for treatment consultation. While it was clear that the wound specialist never looked at the pressure sores in person, local General Practitioner (GP) physicians did check in on her without necessary reviewing the pressure sores. According to record, several months after their development, a GP did eventually look at the sacral wound.

The elderly patient was found on a random day in 2015 to be struggling with elevated blood pressure, body temperature, and heartbeat. She was also noted by the care staff to be breathing very rapidly. The nurses made the decision to have her taken to a local hospital where she was administered high-powered antibiotics for sepsis.

Initially, the octogenarian responded very well to the infusion of antibiotics, but a few days later succumbed to the sepsis. The pressure wounds were determined by an overseeing GP at the hospital to be the likely cause of the bed sore infection and subsequent death.