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My uncle is 90, used a walker, but lived by himself in his own house. He went out every day, drove, walked on a treadmill, etc. up until three months ago. He fell in his house and was there on the floor for two days until the neighbors realized and got him to the hospital. He had unstable spine fractures, but was on blood thinners, so it took two weeks of him lying in bed before they had him ready for surgery. He made it through that but after more hospital time followed by rehab, he isn't able to walk, can move his legs but not much, is weak in the left arm and leg, and can't really move himself to even turn in bed. He can eat on his own and can move himself slowly in a wheelchair with his arms, but can't get in or out of bed or the chair himself. Not clear if the left side weakness was due to a stroke at some point or his lying on it for two days when he fell. He had swelling after the fall, but that has gone away. Not clear how much rehab he actually got in the rehab facility. I live out of the area and was there for the surgery and when he moved out of rehab, but not for the two months in between, so I can't say firsthand what was done. From what I've heard it wasn't much and it wasn't every day.


Rehab discharged him without much warning and the social worker told my sister she just learned he had a stage 3 pressure wound. My uncle told me afterward that they had been treating the wound for a few weeks. My sister wanted him in assisted living since she could not take care of him herself, but the AL would only take him if he was in hospice so that there was a hospice nurse to treat the wound. So he went into hospice at the AL.


Hospice nurse comes a couple times a week and nurses assistants also come. Nurses said the stage 3 wound was fairly small when they first saw it, but it is getting worse in the two weeks since then, has dead tissue, but is clean and not infected. Plan is to keep it clean and not do anything else. AL people are supposed to shift him every two hours, but don't unless he asks, so he is in the bed at night and in the wheelchair basically all day. Nurse has told them they need to move him more, but I don't know if it will happen. They seem very nice and attentive, but this doesn't seem to be what they are used to. My uncle has a reasonable appetite and eats his meals, but he orders what he wants and probably isn't getting enough protein for the wound. The nurse seems very thorough and responsive. She doesn't think the wound will heal with what they are doing, but it seems to be all she can do. I've asked about PT thinking if he could move himself more it might help with the wound. Not sure if it would help or not. His legs haven't moved much for several weeks and they hurt when he is moved in bed or to the wheelchair. Hospice won't do PT, but they can cover a one time evaluation to get recommendations on exercises they might do with him. The nurse doesn't think he will ever walk, which may be right. Not sure if he could gain some motion back though.


The question is if it makes sense for him to be in hospice or if we should be doing something else. He is not in good shape, but as far as what I know, the immobility and the wound are what are wrong. He doesn't have cancer or heart failure or anything else that you would expect to be fatal. He isn't diabetic. If the current situation isn't right, what are the options? Not sure who to even ask. As an added twist, the primary care doctor he had for years basically vanished a month or two ago. Gone without a forwarding address and the only one left in the office is a nurse practitioner who doesn't return calls. So the care he has now is all through the hospice provider.

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Has Hospice ordered an Alternating Pressure mattress for the bed? If not they should have done so. While they do not replace re-positioning a person it does make it easier and the mattress constantly moves so that there is no pressure for any length of time in any one spot.
IF you want to go to more medical care he would have to be discharged from Hospice.
He may be better in a Skilled Nursing facility. AL is not equipped to handle acute medical situations.
You can ask the Hospice Nurse or Social Worker to find out if there is a Skilled Nursing facility that would accept him. If so you could then decide if you want more aggressive care.
It does sound like he may not survive aggressive surgery if that is recommended. His circulation might not be good enough to help heal a wound such as that.

Sorry.
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You could ask for him to be seen by a wound care clinic or clinician for help for the pressure sore. RNET nurses specialize in wound care. I use to sell products for wounds years ago so there are new products out there too. Silver was used on burns but also colloidal silver is very good for many skin problems. Taking Vit. C and Zinc can help. Hydrogen peroxide or saline solution are good for cleaning out wounds. Nurses usually used saline solution. There are bandages that can protect the wound. Usually stage 3 and 4 aren't painful since the injury is below nerve endings. Stage 1 and 2 pressure sores are more painful. Turning the patient every two hours helps. Also the patient may need an air bed that fluctuates and takes pressure off to help with healing. Prayers for healing.
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Thanks for the responses from everyone. They were very helpful in knowing what to ask about and expect. After talking to a some other facilities and describing the situation, they all said it sounded like he was on the border of whether he needed AL or skilled nursing. AL should in theory be able to follow the instructions from the hospice nurse to turn him etc., but it may be more than they can actually manage. Skilled nursing might be what is needed for the wound along with debriding. My sister sounds reluctant after the previous experience with skilled nursing at the rehab facility and because she thinks debriding will require general anesthesia and coming off blood thinners for awhile, which have risks that we learned about when he had the back surgery.
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JoAnn29 Jul 2023
Long use of blood thinners can be a problem. People have problems with internal bleeding. I found this.

"Since anticoagulants thin the blood, patients that experience a chronic wound are at risk of excessive bleeding, or their healing process may be slow. For instance, an unusual wound healing complication caused by anticoagulants is skin necrosis, which can occur using heparin or warfarin (Coumadin)."

JoAnn29
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I am surprised Hospice took him on for just wound care. Yes, you can become sepsis from one and die, so maybe that is the reason.

I think you expect too much from the AL. Its not skilled nursing. Great place for ur Uncle if he didn't have the wound. You need to talk to the head RN and see if turning Uncle is a problem. Maybe the aides are not doing what they have been instructed to do.

I would wonder where the wound started. My DD is a woundcare and admitting RN. When a patient is brought into her Rehab, they are checked from top to bottom for "pressure points"(redness on the heals, butt or elbows) or pressure sores. If any of these are found its documented and an air mattress ordered. My DD follows up with woundcare. If this wound started in the hospital, its their fault. If at Rehab its their fault. And knowing it was present when he was discharged, the Rehab should have set him up with an "in home" wound care nurse. I don't think Hospice needed to be involved. In home is paid by Medicare too.
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Perhaps try skilled nursing facilities , but not the one he was already in . They didn’t sound good .
You can check the Medicare website for ratings to find a better one.
He could go to skilled nursing facility , on palliative care and receive some PT and wound care and a dietitian to help with dietary needs for healing .

The dead tissue in the wound needs to be debrided ( removed ) by a doctor for it to heal.
However , unfortunately he may not improve , deep wounds like this can kill .
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You can sue for pressure wounds..that is called abuse... It is hard to find another facility to take in a patient with stage 3 or 4 pressure sores.

Stage 4 is when it hits bone, if I recall correctly.. deep wounds...

The skin is just not so strong when you get older...

Lots of protein will help the body heal a bit faster. Make sure you get him lots of protein shakes, soup.. whatever.. It helps... Ensure...
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so pressure wounds are horrible... They go from bad to worse in days... They do kill.

when you get older, blood flow isn't so good if you cannot move around yourself. Depending on someone to turn you... make sure your diaper is not too tight (ya, think that's what got my aunt), make sure that the heel is not just laying on the floor while she sits there in the wheel chair for 6 hours (?) what? So, she was in a few facilities...yup... everyone seemed to have failed... overworked? too tired? I don't know, but you got to be tough to help your geriatrics out... that is a tough job.. The skin, muscles, body, soul... the care taker of the heel situation was trying to tell me I could not remove the soaking bloody bandage from my aunt's heel, that a doctor had to do that... What the hell? I got her out and into another facility immediately... They didn't stop me... I could have sued.. and won... !
PRESSURE WOUNDS ARE PREVENTABLE... THEY ARE NOT SUPPOSED TO HAPPEN THOSE ARE FIRST CLUE OF BAD CARETAKING...

THEY COME ON FAST, BUT SLOW TO HEAL...
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They got him an alternating air mattress from the beginning and the hospice nurse ordered a special cushion for the wheelchair when I asked this week and it came the same day. She also got him a wedge pillow for the bed.

The previous facility says it specializes in short term rehab and skilled nursing after hospital stays, so you would think they evaluated him, but I don't know. According to my sister, they called her and said they were discharging him in two days, which was a week earlier than what they said previously, and asked where she wanted him to go. So it seems they weren't much help.

My sister is the one designated to make decisions and she says she called a few places and the AL plus hospice was the only one that would take him. I'm trying to piece this together and figure it out second hand, so I don't know how accurate that is.
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I toured assisted living facilities and skilled nursing facilities. The skilled nursing facilities had the rotating air mattresses.

There are special pillows for people who sit in a recliner or other type of chair all day too.
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"alternating" not alternately.
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For starts, he needs an alternately air pressure mattress. Hospice should order one.

It sounds like he actually needs skilled nursing care. Has he been evaluated for that?
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