Frank L. Williams didn't have bedsores when he left Kenmore Mercy Hospital and entered a nursing home for rehabilitation after a stroke.
That fact is established in a document detailing his condition when he entered Safire Rehabilitation of Northtowns in the Town of Tonawanda.
Four months later, when he returned to Kenmore Mercy, the 82-year-old retired ironworker had seven bedsores on the lower half of his body. He died 14 days later from cardiac arrest caused by sepsis – an extreme response to infection – according to his death certificate. Hospital records cite infections from bedsores as the most likely cause of the sepsis.
"They told me this is the worst case of bedsores they have ever seen from that nursing home," his son, Mark F. Williams Sr., recalled doctors and nurses telling him in the emergency room. "The sores were black. I'd never seen that before. I was shocked. I thought it was the black plague."
Williams' case illustrates how vulnerable individuals who go to poorly rated and understaffed nursing homes for rehabilitation can quickly succumb to preventable but lethal ailments like bedsores.
A New York State Health Department spokesman declined to say whether an investigation into Williams' death was conducted, citing "privacy concerns," but inspection records show Safire Northtowns wasn't cited for the care provided to Williams in late 2016.
However, health department inspectors cited the facility three times from 2015 through 2018 for failing to provide proper treatment and prevention of bedsores to other residents. Those violations included conditions inspectors observed two days after Williams was transferred to Kenmore Mercy.
Among the 47 nursing homes in Erie and Niagara counties, Safire Northtowns had the worst record for residents with bedsores in 2017, according to data from the federal Centers for Medicare and Medicaid Services. Nearly 13 percent of the long-term, high-risk residents at Safire Northtowns had bedsores. That was almost double the statewide average of 7 percent at nursing homes in New York. Only 43 of about 620 nursing homes statewide in 2017 had a higher percentage of long-term residents with bedsores than Safire Northtowns.
In the first two quarters of 2018, the latest available, Northtowns' bedsore percentages have grown even worse, with 16 percent of its long-term, high-risk residents having pressure sores in the second quarter.
Michael Balboni, a Safire Northtowns spokesman, said the facility has higher percentages of residents with bedsores, in part, because it accepts a greater number of obese individuals than other nursing homes. Of the 85 residents at the nursing home, he said, 12 are bariatric patients.
"Care of patients with this condition requires specialized equipment, beds and chairs, and is more complicated," Balboni said.
Obesity, however, should not result in bedsores if a facility is providing proper care, according to a medical official and a wound treatment researcher.
"Because you have accepted bariatric patients, you have a responsibility to have appropriate staffing to reposition them without dragging them," said Dr. Laura E. Edsberg, director of Daemen College's Center for Wound Healing Research.
Safire Northtowns, a 100-bed facility, ranks low in the federal government's five-star rating system. Its overall rating is one star, which is "much below average," according to the U.S. Centers for Medicare and Medicaid Services. Ten of the 47 nursing homes in Erie and Niagara counties are rated that low.
Bedsores, also known as pressure ulcers, occur when a section of the body is pressing against a surface for too long and not repositioned to alleviate the pressure. Several other factors, such as nutrition, the surface on which the body is pressing and moisture also contribute to bedsores, according to experts in the prevention of these injuries.
Yet there is consensus among nursing homes and other health care providers that most bedsores can be prevented.
Several years ago, nursing homes, hospitals and the Health Department assembled the best practices for preventing and treating bedsores. The effort paid off, said Nancy Leveille, executive director of the Foundation for Quality Care at the New York State Health Facilities Association, an industry group. The statewide average of bedsores among long-term residents dropped from 13 percent to 7 percent.
But Mark Williams, who sued Safire Northtowns in May, says the nursing home failed to provide proper care for his father. The lawsuit was filed by attorney Michael Scinta of the Brown Chiari law firm.
Caitlin Robin & Associates, the law firm representing Safire Northtowns, denied the allegations in a response to Mark Williams' lawsuit in State Supreme Court. A lawyer at the firm declined to comment on the case.
Safire Northtowns has also been sued by the family of another man, which alleges he developed severe bedsores in 2016 while at Safire Northtowns because of the nursing home's negligence. That case is also pending.
Bedsore lawsuits can be costly. Earlier this month, a Niagara County jury awarded $1.25 million to 72-year-old Shirley Burrows after determining Newfane Rehab & Health Care Center was negligent in its care of her bedsores.
The state Health Department can also cite or fine nursing homes for allowing bedsores that are deemed avoidable.
Problems from the start
Frank Williams raised his family on the Tuscarora Indian Reservation in Niagara County, where he and his late wife had operated a smoke shop.
After he suffered a stroke, he was treated at Kenmore Mercy Hospital, according to medical records. He was transferred to Safire Northtowns on Sept. 9, 2016.
Public records do not provide many details about his stay at Safire Northtowns, but his son provided an account.
"He was placed in long-term care for three days. I had to tell them he was a rehab patient. They didn't have a bed for him in rehab. The place smelled of urine and it was hot. There were no open windows and my father was sweating," Mark Williams said.
With assistance, Williams could walk. But when he was in bed, the son said, caution was necessary. His father was restless.
"He liked to roll. I'd asked them to place rails on the sides of his bed," Mark Williams said.
The request, he said, was not addressed.
"One day when I came in, he had a big old bump on his head. I asked, 'What happened to you?' He said, 'Oh, I fell out of bed.' The nursing home never told me about that," the son said.
Mark Williams said the nursing home staff informed him in early December 2016 that his father had developed a bedsore in the groin area.
"We were told it was a little pressure sore. I asked, 'Can we look?' and we were told, 'No,' " Mark Williams recalled.
Frank Williams, who had diabetes and high blood pressure, had also been diagnosed with a urinary tract infection, according to hospital records.
In the coming days, Mark Williams said, he noticed his father's health deteriorating.
'Down to the bone'
On Dec. 7, 2016, Frank Williams was readmitted to Kenmore Mercy Hospital because of generalized weakness, a cough and fever, hospital records stated.
After he arrived, hospital records note, Kenmore Mercy staff discovered bedsores on the lower half of his body, including one with "foul smelling drainage" and greenish gray and black spots, along with dead tissue.
According to hospital medical records, there were bedsores on his lower back, right ankle, right and left heels and right big toe. There were two lesser wounds on his right pelvis and scrotum.
"The sore on his right ankle looked like it was down to the bone," Mark Williams said.
Doctors removed dead tissue and muscle from Williams' lower back, scrotum and ankle, medical records stated. So much tissue was removed in his rectal area, that a colostomy bag was required, according to Scinta, Williams' attorney.
"The doctors told us that they had gotten to the point where they were down to his tail bone and couldn't do anything more," said Mark Williams.
Williams' attorney said the bedsores could have been prevented if the nursing home staff had regularly changed Williams' position in bed.
Safire Northtowns is operated by a limited liability company with five New York City area partners: Judy Landa, Richard Platschek, Solomon Abramczyk, Robert Schuck and Moshe Steinberg, according to Health Department records.
Theresa Lyman, administrative organizer for the union that represents certified nursing aides at Safire, said the facility's estimated 80 certified nursing assistants and licensed practical nurses were cut to 38 after the partners bought the nursing home in 2014.
"If there are not workers, how can you change a resident's position?" said Tanya Goffe, a certified nursing aide at Safire, said when asked about the high percentage of bedsores at the facility. Goffe and other unionized nursing home workers rallied in June against the staffing cuts by out-of-town owners.
Balboni, the spokesman for Safire Northtowns’ owners, said the owners have hired nonunion certified nursing assistants to supplement the hours worked by the nursing home’s staff. The total hours worked by all certified nursing assistants – union and nonunion – have not decreased, he said.
"We believe the cause in the bedsore percentages is taking in bariatric patients, not staffing cuts," Balboni said.
An expert's insights
While repositioning is the No. 1 preventive measure for bedsores, there are other necessary steps to avoid pressure injuries, according to Edsberg at the Center for Wound Healing Research.
They include closer attention to the different surfaces the skin comes in contact with, whether it is on a bed or in a chair, and the friction that causes.
"It all comes down to what are the different forces on the tissue. When a bed is raised up, you start to slide down the bed and there is friction," Edsberg said.
Able-bodied individuals can shift to lessen pressure when they become uncomfortable. But nursing home residents may not have that ability, said Edsberg, a former president and member of the National Pressure Ulcer Advisory Panel, a think tank. Sweat and incontinence can also weaken tissue.
Close watch of residents also figures into prevention and treatment, according to Mark Dirlam, the assistant administrator of Elderwood at Lancaster, the nursing home with the lowest percentage of bedsores in Erie and Niagara counties in 2017.
Nurses at that Elderwood home make daily checks of residents for possible breakdowns in the surface of the skin, Dirlam said.
He said the facility also has a "skin team" that has been in place for several years and conducts weekly rounds to assess and treat individuals with bedsores. Team members include nurses, occupational or physical therapists and a dietitian.
Frank Williams' death
Williams died at 4:10 p.m. Dec. 21, 2016, at Kenmore Mercy.
Williams' son said he remains upset that Safire Northtowns did not tell him how bad the pressure sores were on his father's body.
"I arrived at the hospital a few seconds after he died," Mark Williams recalled. "The nurses told me he had smiled when he died. He finally had relief."