Legal Review & Commentary

Patient suffers from debilitating decubitus ulcers: A $694,000 verdict in Missouri

By Jan J. Gorrie, Esq., and Blake J. Delaney, Summer Associate
Buchanan Ingersoll Professional Corp.
Tampa, FL

News: While recovering from emergency surgery, a 71-year old patient developed decubitus ulcers acute enough to cause nerve damage and necessitate plastic surgery. The hospital staff and two attending physicians failed to closely monitor the elderly patient during recovery despite his known underlying complications, which included alcohol dependency and heavy smoking. The patient brought suit against the providers for the permanent damage he sustained to the sciatic nerve in his left leg. A jury awarded him $694,000. Most of the damages were attributed to the hospital.

Background: The 71-year-old man was taken to the hospital following an automobile accident. As a result of the accident, he sustained a ruptured spleen, which was diagnosed by the emergency department physician. A general surgeon was called, and the patient underwent emergency surgery to remove his spleen. After successful surgery, the patient developed respiratory and hepatic complications that left him bedridden and mostly unconscious. The complications were in part due the fact that the patient was a heavy drinker and smoker.

The patient was placed in the intensive care unit (ICU), where he was under the care of the general surgeon and an intensivist. While in the ICU, the patient’s alcohol dependency caused liver compromise, which resulted in elevated ammonia levels. He was given lactulose to balance the ammonia levels, but it had the side effect of causing severe diarrhea. The diarrhea led to the development of decubitus ulcers, including one stage IV ulcer in the sacral/coccyx area. The ulcer was so acute that it caused permanent damage to the sciatic nerve of his left leg, resulting in the loss of voluntary movement. The stage IV ulcer eventually was treated with plastic surgery, but the nerve damage could not be repaired or reversed.

The patient brought suit against the hospital and his two treating physicians. The plaintiff claimed that the hospital failed to assess him as at high risk for the development of decubitus ulcers despite his underlying conditions and failed to implement a skin care plan upon admission. He also claimed that the hospital should have made certain that he was turned every two hours. The patient further averred that the hospital failed to adequately notify the attending doctors about the progression and severity of the ulcers. As to the physicians, the plaintiff contended that they failed to examine, diagnose, and treat the decubitus ulcers and that they neglected to thoroughly examine the patient’s medical records, which included a decubitus ulcer chart.

The defendants argued that the patient’s ulcers were not preventable because his alcohol dependency caused poor liver function, which required the administration of lactulose even though it caused diarrhea. They also claimed that the patient had poor tissue perfusion due to compromised respiration from 40 years of heavy smoking. The hospital further averred that the nursing staff had turned the patient at least every two hours, provided adequate treatment of his condition, and properly notified the doctors of the development of the ulcers. Both physicians claimed that they were unaware of the ulcers while the patient was under their care. The jury awarded the plaintiff $694,000 and assigned 85% of the fault to the hospital, 5% to the general surgeon, and 10% to the internist.

What this means to you: "There are instances where, even with the best nursing care, certain elderly patients will develop decubitus ulcers. However, liability issues involving decubitus ulcers are extremely difficult if not impossible to defend and rarely won in or outside of the courtroom," says Patti Ellis, RN, BSN, LHRM, a risk management consultant in Miami.

The patient presented with the classic elements for developing decubitus ulcers — he was elderly, suffered from trauma that required emergency surgery for treatment of a ruptured spleen, had a history of heavy smoking and of alcohol dependency, while he hospitalized developed post-op respiratory and hepatic complications, he was bedridden, had diarrhea, and for the most part was unconsciousness.

"These are most definitely high-risk factors for the development of decubitus ulcers and they seem to have been overlooked in this case. Patients must be taken as they present and realize that some will be more prone to becoming more complex and act accordingly," Ellis says.

The Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations requires a complete and well-documented risk assessment of all systems upon the patient’s admission to the hospital. "Given the patient’s history and condition, he should have been identified as high risk for the development of decubitus ulcers," notes Ellis.

The hospital claimed that it documented the patient’s condition on a decubitus ulcer chart, although the physicians claimed not to have seen any documentation to that effect. "Poor documentation is usually a major contributing factor to losing cases like this. Complete and thorough assessment and documentation is a critical component of quality patient care," says Ellis. "Such documentation may offer the evidence needed to show that the health care providers assessed the entire patient and not simply the emergency condition."

Early risk identification and risk prevention are key to appropriate care. Unfortunately, it is not uncommon to see situations where there may be fragmented care, documentation and/or communication regarding skin care assessments, repositioning, and wound care among the health care team.

Hospitals and nursing homes more often than not have the appropriate systems and processes in place for addressing decubitus ulcers. These include the use of nursing assessment tools, flow sheets, written wound-care protocols, posted turning schedules, application of skin protection to pressure points, specialized air beds, and multidisciplinary team rounds. "However, when these systems and processes are not properly utilized, you’re going to have a serious problem. Continuity of care and timely communication between the health care team, principally the nursing staff and physicians, can’t be stressed enough. In this particular case, better communication and improved continuity of care would have likely resulted in earlier intervention and perhaps prevented the development of a progressive stage IV decubitus ulcer as well as the subsequent sciatic nerve injury," notes Ellis.

In closing, she says that "in certain settings the reporting of stage IV decubitus ulcers to adult protective services may be required so be sure to check your individual state’s requirements."

Reference

Zane Murphy v. Lake Ozark General Hospital, William Dryden, MD, and David East, MD, Camden County (MO) Circuit Court, Case No. CV197-231CC.