A woman in her 90s fell at the Villa Tollare nursing home in Saltsjö-Boo and broke her foot, but it took two days before the injury was discovered. She then developed severe pressure ulcers. The staff also repeatedly placed her pressure-relieving boot on the wrong foot. The incident is now classified as a serious care injury.
The incident occurred in June when the pensioner fell during a bathroom visit at the nursing home, which is run by Stiftelsen Stora Sköndal. A nursing assistant on site immediately suspected a serious injury, but the on-call nurse assessed over the phone that the woman could remain at the facility.
Over the following two days, the woman showed signs of pain and a deteriorating general condition. Only then did a regular nurse discover that the woman’s foot was severely swollen and blue. At the hospital, X-rays showed that she had fractured her ankle and her blood count was very low.
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The foot was put in a cast, and after that, the woman had to wear an orthosis around the clock. After about a week, severe pressure ulcers with dead tissue were discovered on her heel, the top of her foot, and her toes. This was reported by Nacka Värmdö Posten.
The Boot Was Put on the Wrong Foot
On several occasions, staff put the pressure-relieving boot on the wrong foot. According to the Lex Maria investigation, this was due to unclear instructions and inadequate documentation. The investigation describes systematic failures that affected communication, routines, competence, and equipment.
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The incident is classified as a serious care injury, and a report has been filed with the Health and Social Care Inspectorate (IVO). The head of elderly care at Stiftelsen Stora Sköndal concedes that procedures were not fully followed and regrets what happened.
Measures concern equipment, training, and routines. The woman’s current health condition is not being commented on, citing patient confidentiality.
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