The National Pressure Ulcer Advisory Panel defines pressure ulcers 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.”[1] Elders in nursing homes are particularly vulnerable to these injuries due to their age and propensity to be in bed or a wheelchair for extended periods.[2]These injuries are very preventable, yet can be serious if not properly treated. Beyond this they are very painful and can put a great deal of stress on elders. When not treated, the injuries can become more severe and have greater complications as time goes on.
Pressure Ulcers have multiple stages.[3] 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.[4] 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.[5] Bruising around the area at this stage may indicate a deep tissue injury. [6] Stage Three pressure ulcers have full-skin thickness loss and occur when subcutaneous fat are possibly visible but bone, tendon or muscle are not.[7] Stage Four occurs when there is Full Thickness Tissue loss.[8] This means that bone, muscle or tendon may be exposed.[9] At this stage surgery is often needed as there is a great risk of infection, sepsis, or other complications.[10] 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”[11]
Deep tissue injuries are also considered a stage of pressure ulcer.[12] These injuries are tough to detect, but can quickly develop from a bruised purple look into Stage Four ulcers. [13] Due to the severity of the ulcers and their inherent preventability, federal regulation of nursing homes has developed a standard regarding them. The regulation states that, based on the comprehensive assessment of a resident, the facility must ensure that—
(1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and
(2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.
This means that the only defense to a violation of this is that the sore developing was unavoidable. If raised the defense would have to show exactly why this is the case.
Given the relevant regulations on pressure sores, it is important to determine if the resident was admitted with them. This requires looking at documentation regarding the patient. The admissions documentation is a great place to start.[14] Likewise Medical Administration Reports and Treatment Administration Records show when medication and treatment were given.[15] Obtaining the Minimum Data Set is also crucial, as it will give important information regarding treatment of the patient (this is required in order for the home to be paid by Medicaid).[16] Comparing discrepancies of these documents is crucial. Finally, obtaining documents which involve the when patients are move is helpful, as repositioning is the most full-proof way to avoid pressure ulcers. Simply doing so every two hours can effectively prevent them from developing.[17] Given this inexpensive method of prevention, it can safely be concluded that pressure ulcers are almost entirely preventable, as implied by federal regulation.
[1] http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/
[2] https://www.nlm.nih.gov/medlineplus/ency/article/007071.htm
[3] http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/
[4] http://www.nj-nursinghomeneglect.com/images/stories/trial_magazine_article.pdf
[5] Id.
[6] http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/
[7] Id.
[8] Id
[9] Id
[10] http://www.nj-nursinghomeneglect.com/images/stories/trial_magazine_article.pdf
[11] http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/
[12] Id
[13] http://www.nj-nursinghomeneglect.com/images/stories/trial_magazine_article.pdf
[14] http://www.nj-nursinghomeneglect.com/images/stories/trial_magazine_article.pdf
[15] Id
[16] http://www.nj-nursinghomeneglect.com/images/stories/trial_magazine_article.pdf
[17] https://www.nlm.nih.gov/medlineplus/ency/article/007071.htm
