The tragedy of pressure ulcers is that they are so preventable. These sores cause elders in nursing homes a great amount of pain but can be avoided with a small amount of preventative measures by staff. They are truly a case where “an ounce of prevention is worth a pound of treatment.” Repositioning bed and wheelchair bound residents every two hours can effectively prevent them from developing.[1] Unfortunately, all too often this care is not given. Instead elders in nursing homes are left to deal with the injuries and possible complications of the nursing home’s negligence.
The National Pressure Ulcer Advisory Panel defines a pressure ulcer as, “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.”
Pressure Ulcers have multiple stages.[2] Stage One is called non-blanchable erythema, and refers to the redness of an area over a “bony prominence.” At this stage ulcers can be difficult to detect, but are very treatable.[3] Stage Two refers to partial thickness, or a mark resembling a rash or as skinned knee. The ulcer is still in the first layer of skin.[4] Bruising around the area at this stage may indicate a deep tissue injury. [5] Stage Three pressure ulcers have full-skin thickness loss and occur when subcutaneous fat are possibly visible but bone, tendon or muscle are not.[6] Stage Four occurs when there is Full Thickness Tissue loss.[7] This means that bone, muscle or tendon may be exposed.[8] At this stage surgery is often needed as there is a great risk of infection, sepsis, or other complications.[9] Beyond this, there are two additional stages. Ulcers at an Unknown Stage contain, “[f]ull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV”[10]
Deep tissue injuries are also considered a stage of pressure ulcer.[11] These injuries are tough to detect, but can quickly develop from a bruised purple look into Stage Four ulcers. [12]
C.F.R. § 483.25(c) states that nursing homes have a duty prevent pressure sores from developing and have a duty to treat them when they have developed. C.F.R. § 483.20(b)(1)(xii) states that homes have a duty to do consistently assess the condition of residents skin. While normally these standards affect reimbursement, they can also be used to show a breach of the duty of care. [13] Minimum Data Sets, Care Plans, and other documents can help to show the standards set out regarding pressure sores have not been met. It is crucial to examine these documents and look for evidence that the pressure ulcer was avoidable.
In order for a pressure ulcer to be unavoidable, it must have “developed . . . even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.”[14]
Given that repositioning every two hours if in bed and every hour in a wheelchair can prevent the sores, it is unlikely that the pressures sores developing is not avoidable. A pressure ulcer is avoidable if, “the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident’s clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.”[15]
Information regarding avoidance must be readily available. C.F.R. §483.75(l)(5) requires clinical records contain sufficient information to identify the resident; A record of the resident’s assessments; the plan of care and services provided The results of any pre-admission screening conducted by the State; and progress notes. With all documents available, plaintiffs hopefully will be able show that the duty of care of care receive the compensation they deserve.
[1] https://www.nlm.nih.gov/medlineplus/ency/article/007071.htm
[2] http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/
[3] http://www.nj-nursinghomeneglect.com/images/stories/trial_magazine_article.pdf
[4] Id.
[5] http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/
[6] Id.
[7] Id
[8] Id
[9] http://www.nj-nursinghomeneglect.com/images/stories/trial_magazine_article.pdf
[10] http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/
[11] Id
[12] http://www.nj-nursinghomeneglect.com/images/stories/trial_magazine_article.pdf
[13] Gruber, Saul, Pressure Ulcers Avoidability. Retrieved from http://www.nj-nursinghomeneglect.com/articles/
[14] Id
[15] Id[/fusion_builder_column][/fusion_builder_row][/fusion_builder_container]
