By Christopher Davey MD

What is a pressure ulcer?

Pressure ulcers, also known as decubitus ulcers or bedsores, are localized injuries to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.  Most commonly they are found on the sacrum, coccyx, heels or the hips, but other sites such as the elbows, knees, ankles, or the back of the cranium can be affected.  They range in severity from mild (minor skin reddening, Stage I) to severe (deep craters down to muscle and bone, Stage IV).

Expert witnesses who are board certified by the American Academy of wound management as a certified would specialist are frequently called upon to testify as to the potential breaches in the standard of care.

Breaches of Standards of Care

Here are two examples of breaches of the standard of care.

First: Failing to prevent an avoidable pressure sore;

Example: An 80 year old lady in a nursing home develops a red area, then a blister on the buttocks. Although the nursing staff notes this while she is being bathed, they do nothing about it. The sores get worse and 10 days later there is a large open wound with yellow drainage and odor, typical of infection. The lady ends up in the hospital, sick and septic. She requires operative treatment, but eventually dies of sepsis (blood infection).

Example: A 76 year old man admitted for “rehabilitation” after a heart attack, sits in his wheelchair almost all day. He develops red areas on his buttocks, and should be limited to no more than 60 minutes at a time in his wheelchair. He should also be given a gel cushion for the time he does spend in the wheelchair. These simple measures are not done and he goes on to develop serious and infected buttocks sores. The sores require operative care, which is dangerous in view of his recent heart attack

Second: Failing to properly treat the patient’s pressure ulcers once they developed;

Example: A 65 year old stroke patient develops a sacral ulcer.

No appropriate treatment is prescribed, even though she is turned frequently. The ulcer becomes bigger and infected, requiring operative intervention, but it never heals due to the underlying sacral bone getting infected (osteomyelitis), which is almost always incurable.

Relevant Standards of Care for healthcare providers in Hospitals, and Nursing Homes

Attorneys and the expert witnesses who are called upon to evaluate bedsores and pressure ulcer claims have established and codified standards of care at their disposal.

Prevent Avoidable Pressure Ulcers. Medicare and Medicaid provide rules that require long term care facilities to provide a base level of care.  Failure to meet the level of care provided by the rules found in 42 CFR 483, Subpart B is a violation of the regulations intended to protect residents.  It is also an indication of a violation of the standard of care by the staff of the facility and the administration of the facility.  Section 483.25(c)(1) provides that a facility and its nurses ensure that a resident who is admitted without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that the sores were unavoidable and that a resident who develops pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.  The purpose of this is to prevent residents from getting pressure ulcers and to promote behavior that allows for the healing of decubitus ulcers.  There are a number of interventions that exist to prevent pressure sores that are identified and explained in more detail below.  For example, the standard of care requires that a patient be turned, provided with pressure relieving devices, be kept clean and dry, and be kept properly nourished.  The standard of care also requires that a patient receive frequent head-to-toe body examinations to look for early signs of skin problems.

One additional source regarding the standard of care is the National Pressure Ulcer Advisory Panel.  The NPUAP is a collection of experts tasked with creating treatment algorithms that show the proper method for preventing pressure ulcers.  In 2009, the NPUAP published a 26-page reference guide on how to prevent pressure ulcers. This reference guide, which is available under the educational and clinical resources tab of the NPUAP website (www.npuap.org), provides a detailed description of what the standard of care requires.

The NPUAP identifies what health care providers in hospitals and nursing homes should address when caring for a patient at risk of developing pressure ulcers:

1. Pressure ulcer risk assessment: The standard of care requires health care providers to conduct a structured risk assessment on admission and as frequently and as regularly required based on patient acuity.  In addition, health care providers should reassess the patient’s risk level if the patient has a change in condition.  The purpose of the assessments is to gauge the patient’s risk of developing a pressure ulcer and to ensure a proper plan of care is implemented to prevent a pressure ulcer from developing.

2. Skin assessment: Likewise, the standard of care requires health care providers to perform assessments to determine the integrity of the patient’s skin and to determine whether a change in the care plan is necessary.  Skin assessments should be performed regularly, although the frequency of inspection may need to be increased if there is any deterioration in the patient’s overall condition.

3. Skin care: The standard of care requires providers to care for the skin in a manner that prevents breakdowns.  This includes, for example, not turning a patient onto a body part that is still reddened from a previous episode of pressure loading.

4. Nutrition: Because a decline in nutritional status can lead to skin breakdown, the standard of care requires providers to ensure patients are receiving adequate nutrition.  This includes offering high-protein supplements and/or tube feeding, in addition to the usual diet, to patients with nutritional risk.  It is important that health care providers communicate with the dietary team to ensure the patient does not become malnourished.

5. Repositioning: The standard of care also requires providers to frequently and regularly reposition patients to prevent sustained pressure being applied to the same part of the body for an extended period of time.

6. Mattress and bed use: Because special devices can also offload pressure to parts of the body, the standard of care requires providers to install special devices, such as low air mattresses, for high-risk residents.

7. Support surfaces while seated: For high-risk patients, the standard of care requires health care providers to consider and use support surfaces, such as wheelchair gel cushions, to offload pressure to parts of the body while the patient is seated.

Failing to do any of the above is a breach of the standard of care.

Once the patient has developed a bedsore or pressure ulcer, attorneys and expert witnesses have well defined standards of care for treatment as well.

Properly treat pressure ulcers.  The standard of care also requires that a resident who has pressure sores must receive the necessary treatment and services to promote healing and prevent infection. This standard of care is supported by Title 42, Code of Federal Regulations, Section 483.25(c)(2).  The purpose of this requirement is to promote behavior that allows for the healing of decubitus ulcers.  There are a number of interventions that exist to promote healing and prevent further skin breakdown.  For example, the standard of care requires that a patient be positioned so that pressure on the ulcer is relieved, the patient is kept clean and dry, and the patient is provided with adequate nutrition to support healing.  The pressure ulcer and surrounding skin should also be cleansed at the time of each dressing change.  Appropriate dressing and treatments should be used, or the ulcer is unlikely to heal.  The standard of care also requires that a facility and its nurses intervene such that a patient who has ulcers heals.  The standard of care also requires that regular and complete assessments be performed and documented so that the necessary interventions can be implemented.  Failing to do any of the above is a breach of the standard of care.

In general, the facility must have sufficient staff to provide 24-hour nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individualized plans of care.  When treating a patient with a high risk of developing pressure ulcers, a facility and its agents must properly and regularly assess the patient, including daily and complete skin assessments, proper documentation of the patient’s daily activities, and monitoring the patient’s body weight. Such accurate and complete documentation is necessary to properly gauge whether the current treatment plan is working. If not, the plan needs to be modified or changed. In addition, staffing levels should reflect the complexity of the care required, the size of the facility, and the type of services delivered. This means that the training, selection, and supervision of the staff must be sufficient to handle the nursing care that is needed by the residents who are accepted into the facility.

The history behind nursing home regulations informs about their purpose.  In the past, most nurses in nursing homes had little or no formal training in gerontology and long-term care. Many nursing home attendants or aides had no formal training.  In 1986, only 17 states had mandated training requirements for nursing attendants, and there were no federal standards for training. In a 1986 study, conducted at the request of Congress, the Institute of Medicine found that residents of nursing homes were being abused, neglected, and given inadequate care. The Institute of Medicine proposed sweeping reforms, most of which became law in 1987 with the passage of the Nursing Home Reform Act, part of the Omnibus Budget Reconciliation Act of 1987. The basic objective of the Nursing Home Reform Act was to ensure that residents of nursing homes received quality care that resulted in their achieving or maintaining their “highest practicable” physical, mental, and psychosocial well-being.

Implement The Nursing Home Reform Act of 1987. To secure quality care in nursing homes, the Nursing Home Reform Act requires the provision of certain services to each resident and establishes a Residents’ Bill of Rights.  Nursing homes receive Medicaid and Medicare payments for long-term care of residents only if they are certified by the state to be in substantial compliance with the requirements of the Nursing Home Reform Act.  The purpose of these reforms was to ensure that facilities had sufficient staff that was sufficiently trained and supervised to provide quality care to the residents.  Such training and supervision are especially important when it comes to care of dependent residents. Failing to have a staff that is sufficiently trained and supervised, which includes the facilities policies as well as the implementation of those policies, to attain and maintain the highest practicable physical, mental and psychosocial well-being of the residents is a violation of the standard of care applicable to nursing homes.

Bedsore and wound care expert witnesses look to see if the Nursing Home Reform Act of 1987 is followed and implemented.

Failing to implement The Nursing Home Reform Act of 1987

First: This standard of care mandates that a facility and its nurses ensure that a resident who is admitted without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable and that a resident who has pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.

Second: It is the standard of care to promote the healing of a pressure ulcer.

First, the nursing staff should properly, and continually, document on the stage and size of the ulcers, so that the treatment plan can be assessed and modified if needed.

Second, the nursing notes should indicate that the Care Plan is being consistently followed.

Thirdly, a low air loss mattress is one way to assist in the offloading of pressure, especially over sensitive areas like bony prominences. Even with this, however, many patients will still need to be turned frequently.

Third: In most states there is a requirement to provide sufficient staff to provide 24-hour nursing care and related services reflecting the complexity of the care required, the size of the facility, and the type of services necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, as determined by the resident assessments and individualized plans of care.  When a resident does not receive frequent and regular assessments and care, it is indicative of an insufficient staff level.  If staffing levels are appropriate, there will be nurses and/or staff available to attend to the resident at all times.

If the care provided to the resident is adequate, they would receive thorough wound care. The resident would also be turned frequently enough to offload pressure. The failure of the facility to provide sufficient staff and to provide 24-hour nursing care and related services is a breach in the standard of care.

Fourth: A facility may violate the standard of care applicable to nursing homes by failing to properly train and supervise its staff and by failing to have policies in place that are designed to maintain the highest practicable physical, mental, and psychosocial well-being. If the staff is properly trained they would understand the importance of regular assessments of all wounds. If  the care is provided by sufficiently trained staff and based on well-conceived policies and procedures, appropriate and timely care plans can be followed through with and interventions can be put in place which would prevent residents from developing an Unstageable pressure ulcer.

How and why pressure ulcers develop is usually explained at deposition and trial by the expert witness.

What causes a pressure ulcer to develop?

Pressure ulcers occur when soft tissues are distorted in a fixed manner over a period of time. This distortion usually occurs when the soft tissues are compressed and/or sheared between the skeleton and a supportive device (such as a bed or chair).  This causes the blood vessels within the distorted tissue to become compressed, angulated, or stretched out of their usual shape.  As a result, blood is unable to pass through the vessels.  When blood is unable to pass through the vessels, the distorted tissues become ischemic.  Ischemia is the shortage of oxygen and nutrients needed to keep tissue alive. If ischemia occurs for an extended length of time, then death of the tissue occurs, a process known as necrosis. Necrotic (dead) tissue usually becomes infected and foul smelling.

Other factors cause pressure ulcers, too. If a person slides down in the bed or chair, blood vessels can stretch or bend and cause pressure ulcers.  Even slight rubbing or friction on the skin may cause minor pressure ulcers.

How does the failure to comply with the standard of care cause severe pressure ulcers?

The standards of care discussed above related to preventing pressure ulcers all focus on identifying those at risk for the development of pressure ulcers and providing the interventions necessary to prevent the development of the ulcers.  When a facility or its nurses fail to have, enforce, or enact the appropriate measures to assess a person’s risk for developing a pressure ulcer, then the person does not receive the necessary care to prevent the development of ulcers.

When a facility or its nurses fail to have, enforce, or enact the appropriate interventions to prevent the development of ulcers, then the patient or resident is more likely than not going to develop ulcers.

Once an ulcer develops, the standard of care shifts from prevention to treatment, as detailed above.  According to the recommendation of the National Pressure Ulcer Advisory Panel (NPUAP) Consensus Development, the following describes the staging of pressure ulcers:

Stage 1

Nonblanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators.  A Stage I pressure ulcer is an observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.

Stage 2

Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. NOTE: Stage I and Stage II pressure ulcers can almost always be successfully and simply treated so that they do not progress to the more serious Stage III or Stage IV.

Stage 3

Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

Stage 4

Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule).  Undermining and sinus tracts also may be associated with Stage 4 pressure ulcers.

Stage III or Stage IV are much more difficult to treat.

Unstageable/Unclassified

Full thickness tissue loss in which the base of the ulcer is completely covered 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 is removed to expose the base of the wound, the true depth and stage cannot be determined.  However, it will be either a Stage III or Stage IV.

Suspected Deep Tissue Injury (SDTI or DTI)

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar.

Evolution may be rapid exposing additional layers of tissue even with optimal treatment. DTIs are usually related to trauma.

The standards of care related to treatment are intended to prevent ulcers from progressing from a Stage I or Stage II wound to a Stage III or Stage IV wound.  When insufficient care is provided to treat ulcers and the ulcer progresses to a Stage III or a Stage IV wound, then the patient or resident suffers a number of complications directly caused by the failure to assess, prevent, and treat ulcers.

How do severe pressure ulcers impact residents and patients?

First, and most obviously, Stage III and Stage IV pressure ulcers impact the skin.  These ulcers cause skin loss with extensive destruction, tissue necrosis, and damage to muscle, bone, tendons, and other supporting structures.  These types of ulcers frequently require surgical intervention, such as debridement (removal of dead or infected tissue), skin grafts or flaps. Second, patients and residents who have severe ulcers, have a hugely increased morbidity and mortality rate. Death from sepsis related to a Stage III or Stage IV pressure ulcer is common. The death is frequently slow and painful. Third, patients and residents who have severe ulcers become susceptible to infection and other medical complications related to the wound and its treatment.  Fourth, the patients and residents who develop severe ulcers have problems with pain and loss of dignity associated with the wound and its treatment. For example, chronic sepsis and pain will often cause a patient to stop eating, further contributing to a terminal decline, which often results in a Hospice referral.

 

About the Author:

Dr. Davey has practiced in Family Practice and Geriatric Medicine since 1987. He has a special interest in wound care diagnosis and treatment. He is Board certified by the American Academy of Wound Management as a Certified Wound Specialist (CWS) and is a trained Hyperbaric specialist. Dr. Davey has testified extensively for both plaintiff and defense in cases involving geriatric issues, falls, bedsores, pressure ulcers, complex medical cases and standards of care. His pathology background gives him the expertise to render opinions on cause of death issues.