Legal Review & Commentary

Development of decubitus ulcers leads to death, $250,000 verdict in Ohio

By Blake Delaney, Buchanan Ingersoll PC, Tampa, FL

News: An 83-year-old nursing home resident developed severe decubitus ulcers. After the nursing home failed to treat the ulcers, they became infected, and the woman subsequently died. Although the decedent's family attributed the death to the infected decubitus ulcers, the nursing home claimed that her death was the result of underlying complications. The jury awarded $250,000 to the plaintiff.

Background: The plaintiff's decedent, aged 83, was admitted to the nursing home in June 2001. Three days later she was admitted to a hospital, but she was returned to the nursing home 11 days later. The nursing home subsequently discovered that the woman had developed severe decubitus ulcers on her feet and body.

Decubitus ulcers result from pressure being exerted on the skin, soft tissue, muscle, and bone by the weight of an individual against a surface beneath. In patients who are unable to avoid long periods of uninterrupted pressure over bony prominences, such as the elderly, neurologically impaired patients, and patients who are acutely hospitalized, the risk of necrosis and ulceration developing increases. In fact, two-thirds of pressure sores occur in patients older than 70 years of age; the prevalence rate in nursing homes has been estimated to be 17-28%. (Revis DR. Decubitus ulcers. Web: www.emedicine.com/med/topic2709.htm.)

Decubitus ulcers in nursing home patients often form from a constant compression of the tissues by an external force, such as a mattress, wheelchair pad, or bed rail. Irreversible changes may occur after as little as two hours of uninterrupted pressure. No surface of the body can be considered immune to decubitus ulcers if they experience long periods of uninterrupted pressure.

The most widely accepted classification system for staging decubitus ulcers is that of Shea, as modified to represent the present National Pressure Ulcer Advisory Panel classification system. This system consists of four stages of ulceration, but not all decubitus ulcers necessarily follow a standard progression from Stage I to Stage IV. Instead, the system describes the depth of a decubitus ulcer at a specific time of examination in order to facilitate communication among the various disciplines involved in the study and care of such patients.

Stage I ulcers are characterized by intact skin with signs of impending ulceration. Stage II ulcers demonstrate a partial thickness loss of skin involving epidermis and possibly dermis, possibly manifesting as an abrasion, blister, or superficial ulceration.

Stage III decubitus ulcers have a full thickness loss of skin, with extension into subcutaneous tissue (but not through the underlying fascia). Finally, Stage IV ulcers are characterized by a full thickness loss of skin and subcutaneous tissue and extension into muscle, bone, tendon, or joint capsule.

The plaintiff's decedent in this case exhibited massive stage IV decubitus ulcers, which became infected after having been left untreated by the nursing home facility. Ultimately, the woman developed sepsis and subsequently died. Her estate brought suit against the nursing home, claiming that steps should have been taken to prevent the pressure ulcers by turning and repositioning the patient every two hours. The plaintiff also claimed that once the ulcers developed, staff should have treated the infection more aggressively.

The defendant nursing home maintained that her underlying health issues, not the care and treatment of the ulcers, were the cause of her death. A $250,000 verdict was returned.

What this means to you: Although the facts are not clear as to when the patient developed her decubitus ulcers, this case raises issues of patient skin assessment and care at the point of admission and during a patient's stay at a health care facility. At the point of admission, it is important to assess a patient's skin to determine what kind of care plan is required for the patient.

"Every patient should undergo a full-body initial skin assessment as soon as they are admitted in order to determine the potential of skin breakdown," says Kenneth R. Nanni, PhD, health care risk manager and director of the Graduate Certificate in Health Care Risk Management Program at the University of Florida in Gainesville.

This assessment should include documenting all pressure ulcers for location, size, stage, the presence of any sinus tracts, undermining, tunneling, exudate, and necrotic tissue, Nanni advises. The admissions staff also should assess whether the patient has any contributing medical, nutritional, or hydration problems.

From a risk perspective, the initial assessment should be a standard procedure performed on all residents, and the results of the screening should be documented fully and accurately. "If the patient is determined to be at high risk for skin breakdown, then the facility must develop an appropriate initial nursing care plan," says Nanni.

This case also raises concerns about how the sore was permitted to develop into a stage IV decubitus ulcers if, in fact, the patient was admitted with no signs of pressure sores.

"Every facility, but especially long-term facilities which treat those who are prone to skin breakdown, should have policies in place to treat patients who develop decubitus ulcers after admission," notes Nanni.

Such a policy initially should include formulating a plan of wound care that involves the entire treatment team, including the physicians and wound care specialists, he advises.

The first step in resolution is to reduce or eliminate the cause (i.e., the pressure). Many options are available, including specialized support surfaces for bedding and wheelchairs, such as foam devices, air-filled devices, low-air loss beds, and air-fluidized beds.

Regardless of the support surface used, the focus of the treatment should be on turning and repositioning the patient. Repositioning is often performed every two hours, even in the presence of a specialty surface or bed. Further, the wound and surrounding skin must be kept clean and free of urine and feces, and bacterial contamination must be assessed and treated appropriately. The wound must be appropriately dressed, which may vary, depending on the stage of the wound, from simply applying a hydrocolloid occlusive dressing to using an isotonic sodium chloride solution with vacuum-assisted closure sponges.

Finally, the patient's nutritional status should be optimized, which may include dietary supplements, enteral feedings, or even parenteral feedings. Nanni emphasizes that every aspect of the wound care treatment plan be documented in the patient's medical chart.

A policy for preventing and treating decubitus ulcers extends beyond the treatment plan. "Equally important to a facility's skin breakdown policy is appropriate training of the staff, including the direct care CNA [certified nursing assistant] staff," says Nanni. This training should educate team members on the early identification of pressure ulcers and on properly documenting orders, such as an "order to turn resident every two hours.

"Furthermore," Nanni says, "a facility's policy should outline the procedure for the reassessment of all pressure ulcers on a routine basis by the nursing staff." Nanni notes that when necessary, this could include providing a surgical consult for debridement, the process of removing de-vitalized, or dead tissue from a wound bed.

Nanni is concerned with the risk control techniques exhibited by the defendant long-term care facility in this case. Nursing homes must have in place a standard admissions procedure, which demands the performance of full-body skin assessments and the development of initial nursing care plans for all patients. Further, such facilities must ensure that positioning and wound care techniques are in place so that decubitus ulcers are not permitted to develop or get worse once discovered.

Nanni advises facilities to implement appropriate daily skin assessments and reporting processes so that the CNA staff can be the first line of defense. "How could this sore have developed to a stage IV decubitus ulcer?" he questions.

Reference

• Cuyahoga County (OH), Court of Common Pleas, Case No. 486250.