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The Pressure Sore Case: a Medical Perspective

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The Pressure Sore Case: a Medical Perspective Marquette Elder's Advisor Volume 2 Article 7 Issue 2 Fall The rP essure Sore Case: A Medical Perspective Jeffrey M. Levine Follow this and additional works at: http://scholarship.law.marquette.edu/elders Part of the Elder Law Commons Repository Citation Levine, Jeffrey M. (2000) "The rP essure Sore Case: A Medical Perspective," Marquette Elder's Advisor: Vol. 2: Iss. 2, Article 7. Available at: http://scholarship.law.marquette.edu/elders/vol2/iss2/7 This Featured Article is brought to you for free and open access by the Journals at Marquette Law Scholarly Commons. It has been accepted for inclusion in Marquette Elder's Advisor by an authorized administrator of Marquette Law Scholarly Commons. For more information, please contact [email protected]. The Pressure Sore Case: A Medical Perspective Although bedsores sometimes result dents.7 As a result, malpractice litigation related to pressure sores exploded in the 1990s.1 from inadequate care, not all cases Clinical Practice Guidelines involving pressure ulcers merit a law- Define Pressure Sores suit. This article adopts a medical per- Clinical practice guidelines define a pressure ulcer as "[a]ny skin lesion, usually over a bony promi- spective in its consideration of the pres- nence, caused by unrelieved pressure resulting in damage of underlying tissue." 9 The incidence of sure sore case, particularlywhen evalu- pressure ulcers in nursing homes is 0.20 to 0.56 per 1,000 resident-days, which may increase to 14 per ating deviation from the standard of 1,000 resident-days among those at high risk.' ° Commonly affected sites, comprising approximate- care. ly eighty percent of wounds, are the pelvic girdle (lower portion of the hip bone), sacrum (lower By Jeffrey M. Levine, M.D. back below the waist), coccyx (tail bone), trochanter (hip bone), and heels." A resident with a pressure ulcer has a two to six times greater mor- 2 ressure sores, also known as pressure tality risk than one with intact skin.' ulcers,' bedsores, decubitus ulcers, or decubiti,3 are an unfortunate common Identify Residents at Risk for Pressure Sores occurrence in older nursing home resi- Seventy percent of pressure ulcers occur in persons 13 dents. In the nineteenth century, pressure over age seventy. Pressure ulcers are most likely to ulcers were viewed as the inevitable result of debil- form in residents with a chronic preexisting illness ity and neurologic illness.' Today, we know that such as coronary artery disease, peripheral vascular pressure sores often are preventable.' Yet, despite disease, cancer, and diabetes mellitus. 4 Table 1 pre- extensive education, research, and regulation, they sents other risk factors."s Medical conditions sur- continue to occur among older nursing home resi- rounding pressure sores are complex and require individual assessment for each resident. Assessing the Pressure Sore Case Jeffrey M. Levine, M.D. is Assistant Medical Director The Omnibus Budget and Reconciliation Act of of Kings Harbor Multicare Facility, Bronx, New York, 1987 (hereinafter OBRA '87)6 sets forth rules for where he serves as director of wound-care. Dr. Levine quality of care and quality of life that govern trained in geriatric medicine at the Mount Sinai 7 Medical Center in Manhattan, and frequently lectures Medicare and Medicaid certified nursing homes.' and writes about pressure sores and other long-term The statute establishes an industry standard of care care issues. not unlike clinical practice guidelines. An expert 44 ARTICLE The Pressure Sore Case: A Medical Perspective 45 Table 1. Pressure Sore Risk Factors Were Preventive Measures Considered and * Cardiovascular compromise such as atherosclerotic Implemented? disease Several modalities are accepted as the standard for * Chronic illness that requires bed rest pressure sore prevention, including, but not limited * Dehydration to the following: * Degenerative neurological disease such as dementia * Diabetes mellitus " Placing the at-risk resident on a pressure- * Diminished pain awareness reducing device such as gel- or water-filled * Fractures mattress * History of corticosteroid therapy overlays, a foam overlay, or an air- * Immobility filled overlay; * Immunosuppression " Using heel pads to relieve pressure on the res- * Incontinence (urinary and fecal) ident's heels, a common pressure ulcer site; * Malnutrition and * Mental impairment, possibly related to coma, altered " Systematically turning and repositioning the level of consciousness, sedation, or confusion resident to shift the points under pressure. * Multisystem trauma • Musculoskeletal illness such as arthritis These modalities should be in place for the res- • Paralysis ident at-risk for pressure sores. Moreover, the resi- • Physical restraint * Poor circulation dent's medical chart should clearly reflect their use. • Psychotropic drug use Once a pressure sore occurs, pressure relief strate- * History of pressure ulcers gies must be documented and care-planned. Care * Significant obesity or thinness plans must be individualized and tailored to each resident. If pressure sore prevention measures are not documented in the nursing home record, it is familiar with OBRA '87 and its companion regula- difficult for the facility to successfully argue that tions should review the nursing home record. For these measures were taken. example, the law demands detailed periodic assess- ments in the form of the Resident Assessment Was Appropriate Wound-Care Rendered? Instrument (RAI), which is comprised of the Many different treatments are available to suit dif- Minimum Data Set (MDS) and Resident ferent types of wounds. Aside from the wound, a Assessment Protocols (RAPs).'8 These in turn are good therapeutic approach must accompany treat- intimately linked to the backbone of the medical ment of the resident's underlying medical condi- record-the care plan. Reviewing the MDS, RAPs, tion such as diabetes mellitus, poor circulation, or and care plans helps assess critical spheres that poor nutritional status. Nutrition must be an inte- overlap with pressure sore care such as nutrition, gral part of any pressure sore prevention and treat- hydration, continence, and mobility. Knowledge of ment plan. 20 Judicious wound-care necessitates fre- the RAI endows the attorney with a powerful yard- quent reassessment of wound appearance with stick to measure the quality of care delivered to a appropriate changes in dressing modalities. Using resident at risk for, or who has, pressure sores. the wrong treatment or incorrectly using the cor- Whether a pressure sore occurs in the nursing rect treatment may harm the resident. For exam- home or hospital, similar prevention, assessment, ple, wet-to-dry dressings are generally indicated and treatment principles apply. Caregivers must for wounds having slough or necrosis (that is, anticipate the occurrence of skin breakdown and dead tissue). If applied incorrectly to clean intervene with appropriate preventive measures. wounds, their therapeutic benefit is lost and harm The assessment of a wound must be timely and fre- may result by tearing healthy tissue and causing quent. Documentation must satisfy minimum stan- pain upon removal. dards of detail and accuracy. Treatment must be governed by basic wound-care principles, which Was the Documentation Adequate? render some dressings appropriate and others inap- Pressure sores can change from day to day. propriate depending upon the circumstances." Therefore, detailed documentation should appear 46 Elder's Advisor in the resident's record at least once per week and Table 2. Pressure Sore Classifications more frequently if major changes occur. Treatment Stage I: Nonblancheble erythema (that is, redness cannot be ordered without adequate clinical justifi- that does not go away) of intact skin. cation for each specific wound-care modality. Stage 1I: Partial thickness skin loss involving epider- Thus, review of wound documentation is critical in mis, dermis, or both. The ulcer is superficial assessing the quality of care. Poor documentation and presents clinically as an abrasion, blister, hinders the evaluation of such care. or shallow crater. Examine the nursing home record for the fol- Stage IM: Full thickness skin loss involving damage to, or necrosis of subcutaneous tissue that may lowing information: extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep " pressure sore stage classification (see Table 2); crater with or without undermining of adja- " anatomic location of the bedsore(s) (for exam- cent tissue. ple, on the resident's right hip or left heel); Stage IV: Full thickness skin loss with extensive " size (that is, length, width, depth, and tunnel- destruction, tissue necrosis, or damage to ing); muscle, bone, or supporting structures (e.g., " appearance of the wound bed and surround- tendon, joint capsule). ing skin distinguishes viable from nonviable tissue; Table 3. Who Helps Residents " color of wound bed and surrounding skin with Pressure Sores? guides treatment decisions (for example, a change in color may indicate that the wound " Clinical nurse specialists is becoming dehydrated and requires a moist " Dermatologists dressing); " Dieticians " Enterostomal therapy nurses " drainage amount (such as scant, light, moder- " Occupational therapists ate, heavy, or copious), color (described in " Pharmacists the resident's record as clear or bloody, for " Physical therapists example), consistency (such as thick or " Physicians watery), and odor (for example, a pungent,
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