Marquette Elder's Advisor Volume 2 Article 7 Issue 2 Fall
The rP essure Sore Case: A Medical Perspective Jeffrey M. Levine
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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
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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, " Podiatrists strong, foul, fecal, or musty odor suggests " Psychiatrists infection); " Speech-language pathologists * temperature (a feeling of warmth, for exam- * General, plastics, vascular, and orthopedic surgeons ple, may indicate pressure ulcer formation if Chart entries regarding the resident's skin con- the skin is intact, or signal the presence of an dition may appear simultaneously in several loca- underlying infection); and tions. For example, the decubitus should be docu- " pain or tenderness and absence thereof. mented in the MDS, care plan, nursing summaries, nursing narrative, and physician notes. Locate It is common for pressure sores to be inade- additional documentation on skin care flow sheets quately or incorrectly described in the resident's and treatment records. Different facility personnel, medical record. Descriptions of sores from differ- including physicians, nurses from different shifts, ent facilities may conflict with one another. These nursing assistants, as well as nutritional and reha- facts are of utmost importance in building a case of bilitation personnel, generally make entries. As negligence against or in defense of a facility. such, record alteration or falsification is difficult and easy to detect. "Color photocopies are highly Was the Documentation Consistent? recommended, are worth the increased cost, and in Correct treatment of pressure sores usually many instances will assist you in finding falsifica- involves multiple disciplines. Table 3 provides a list tion of the records."2' In practice, facilities with of likely consultants to care for residents with pres- poor skin care programs show gaps and inconsis- sure ulcers. tencies in pressure sore documentation. Gaps, ARTICLE The Pressure Sore Case: A Medical Perspective 47
inconsistencies, changes, or falsification in docu- Was the Resident's Pressure Sore Unavoidable? mentation spell trouble for a facility involved with Federal regulations require that a nursing home litigation related to pressure sores. "ensure that [a] resident who enters the facility without pressure sores does not develop pressure Was Documentation Supplemented with sores unless the individual's clinical condition Photographs? demonstrates that they were unavoidable."22 Wound documentation may be supplemented with Explore the issue of unavoidability when evaluat- photographs. These photographs serve medical and ing a case for litigation. Unavoidability is a com- legal purposes. In practice, the wound is pho- mon, and sometimes effective, defense argument. tographed in color on initial assessment and then Judge unavoidability within the context of caregiv- daily or at select intervals for long-term manage- er efforts to prevent skin breakdown. There are no ment. Photographs are powerful demonstrative firm guidelines that govern the determination of aids during a trial. Ask whether the facility, hospi- unavoidability. This question remains the subject of tal, family, or friends took photographs of the resi- intense debate among nursing home surveyors, dent's pressure ulcers. The nursing home and treat- nursing home personnel, clinicians, and attorneys.23 ing hospital should take photographs of any Severity of the resident's preexisting illness may observed pressure ulcers, not only for their own bolster an argument for unavoidability. However, protection, but also to adequately stage the devel- the interplay of disease, mobility status, and skin opment of the pressure sores. condition is extremely complex and must be taken on a detailed case-by-case basis. Were Nutritionistand Rehabilitation Subspecialties Involved? Expert Review Subspecialty consultation may be required for resi- Residents with pressure sores often have multiple dents with pressure ulcers. For example, malnutri- admissions to hospitals and nursing homes over tion is a risk factor for pressure sore development, long periods of time. Voluminous medical records and, if present, can hinder healing once an ulcer may present an unwieldy organizational and occurs. Therefore, assessment of nutritional man- review task for any medical expert. Make all med- agement is critical when evaluating a case for pres- ical documents available for expert review to sure ulcer litigation. For residents who experience ensure delivery of an adequate expert opinion difficulty swallowing, a speech and language regarding pressure sore occurrence. Expert review pathologist provides diagnostic and therapeutic of medical records prior to bedsore development suggestions enhancing nutritional management, may relate critical information regarding risk fac- while occupational and physical therapists provide tors. Records of subsequent treatment at other critical rehabilitative strategies that enhance facilities (such as a hospital) can confirm complica- strength, mobility, and independence-all essential tions resulting from the wound. in preventing and treating pressure sores. Interim hospital records offer additional ulcer documentation and other diagnostics essential to What Complications Resulted from the verifying the resident's condition as it evolves over Bedsore? time. For example, the nursing home record may Complications resulting from pressure sores add to lack bloodwork demonstrating dehydration, which the gravity of caregiver negligence if deviations may be evident in the hospital admission that fol- from the standard of care occurred. Complications lows. include, among others, infection; sepsis; osteomyelitis; pain; blood loss; and feelings of Survey Reports and Complaint Files humiliation, depression; and death. Pressure ulcers Nursing home survey reports and complaint files may result in the need for plastic surgery or ampu- available from the state department of health may tation of a resident's limb, as well as lengthy peri- reveal citations for skin care deficiencies and relat- ods of rehabilitation. In general, complications ed issues such as nutrition and hygiene, which can stemming from pressure sores increase monetary bolster claims against the home. Surveys may or claims against the facility and/or caregivers. may not reflect a continuing problem of care. For Elder's Advisor
example, a facility cited for pressure ulcer develop- nel turnover. The day-to-day burden of turning, ment in 1994, with no citations on this issue in toileting, and feeding residents often falls on per- 1995 through 1999 surveys, should not have the sons from lower socioeconomic strata. These fac- 1994 survey "unfairly paraded before the court" in tors must be considered in managing a facility a current pressure sore case. 24 because caregiver comfort and satisfaction directly impact the quality of care delivered to residents.3" The Best Defense Conclusion Establish a Pressure Sore Program Experts agree that pressure ulcers represent a qual- Facilities can fight alleged quality deficiencies by ity indicator. That is, a condition which reflects implementing a comprehensive, interdisciplinary, whether adequate care was rendered to an individ- proactive, and multilevel program of facilitywide ual.31 We have made progress with pressure sore pressure sore surveillance and documentation.25 prevention and treatment.32 The coming decades This strategy takes resources and commitment will witness a great increase in America's elderly from management and involves the cooperation of population-a demographic situation unprecedent- physicians as well as nurses. One person alone can- ed in our nation's history. Despite advances in med- not prevent and treat pressure sores, as this chal- ical care and technology, residents still will be at lenge involves every level of caregiver.26 A compre- risk for pressure sores.33 hensive pressure sore program is not an "add-on," Our society is just beginning to prepare for but rather an integral part of facility culture. these demographic changes. The medical establish- When facilities commit to developing compre- ment is building geriatrics curricula in medical hensive skin care programs, pressure ulcers may schools. Organizations such as the American not disappear entirely, but their prevalence will Medical Directors Association, a national profes- decrease. When pressure sores do occur, or when sional organization representing physicians who existing wounds deteriorate, documentation and care for residents in long-term care settings as use of appropriate prevention and wound-care are attending physicians and medical directors, provide more likely to be in place, thereby decreasing liti- educational programs for physicians already in gation risk. practice.34 Federal regulation provides a framework for Risk Factor Detection and Prevention maximizing quality in nursing homes, and the Elements of a comprehensive pressure sore pro- Health Care Financing Administration sponsors gram include a system for risk factor detection and clinical practice guidelines to educate personnel 27 implementation of preventive measures. New and standardize care. However, given the urgency wounds, whether preexisting on newly admitted of the demographics, time is short and the task is facility residents or acquired during residency, must immense. If education and regulation do not suffice be examined expeditiously and entered into a facil- in engendering quality medical care, litigation will itywide tracking system.28 inevitably provide the stopgap measure. Therefore, it is important for the attorney to know which Train and Educate Staff cases to decline and which to pursue. Staff training and education are critical to the suc- cess of any wound care program. 29 Nurses must know how to assess and document wounds. Nursing assistants must know how to provide pre- Endnotes ventive care. Physicians must be knowledgeable 1. See TABOR'S CYCLOPEDIC MEDICAL DICTIONARY 1595 regarding wound-care products and their correct (17th ed. 1993) (defining pressure ulcer or sore). application. Staff education programs must also consider ethical issues and advance directives. 2. See id. at 215 (defining bedsore).
Job Satisfaction 3. See id. at 503 (defining decubitis ulcer). The facility's environment must foster caregiver job 4. See Richard M. Allman, Pressure Ulcers among the satisfaction in order to decrease stress and person- Elderly, 320 NEw ENG. J. MED. 850, 850 (1989). ARTICLE The Pressure Sore Case: A Medical Perspective 49
5. See Jeffrey M. Levine, HistoricalPerspective: The (1994) (detailing wound care treatment modalities) Neurotrophic Theory of Skin Ulceration, 40 J. AM.
7. See David M. Smith et al., Pressure Sores in the 22. 42 C.F.R. § 483.25(c)(1). Elderly: Can This Outcome Be Improved?, 6 J. GEN. INTERNAL MED. 81, 83 (1991). 23. See Smith, supra note 7, at 93.
8. See Richard G. Bennett et al., The Increasing 24. See Byron S. Arbeit, The Administratorand Medical Malpractice Risk Related to Pressure Nursing Home Liability Issues, in NURSING HOME Ulcers in the United States, 48 J. AM. GERIATRICS LITIGATION: INVESTIGATION AND CASE PREPARATION SOC'Y 73, 74 (2000). 111, 126-27 (Patricia W. Iyer ed., 1999).
9. AM. MED. DIRECTORS ASS'N, PRESSURE ULCERS: 25. See Jeffrey M. Levine & Elizabeth Totolos, A CLINICAL PRACTICE GUIDELINE 1 (1996). Quality-OrientedApproach to Pressure Sore Management in a Nursing Facility, 34 10. See id. GERONTOLOGIST 413, 415-16 (1994).
11. See id. 26. See Jeffrey M. Levine et al., Pressure Sores: A Plan for Primary Care Prevention, 44 GERIATRICS 75, 87 12. See id. (1989).
13. See id. 27. See Nancy Bergstrom, Strategies for Preventing Pressure Ulcers, 13 CLINICS IN GERIATRIC MED. 14. See CATHY THOMAS HESS, NURSE'S CLINICAL GUIDE 437, 452-54 (1997). TO WOUND CARE 10 (2nd ed. 1998). 28. See Jeffrey M. Levine et al., Residents Admitted to 15. See id. at 49. the Nursing Facility with Pressure Ulcers: Implications for Morbidity, Mortality, and Quality, 16. See Rebecca Elon & L. Gregory Pawlson, The 3 NURSING HOME MED. 26, 26 (1995). Impact of OBRA on Medical Practicewithin Nursing Facilities. 40 J. AM. GERIATRICS SOC'Y 958, 29. See Betsy L. Moody et al., Impact of Staff 958-59 (1992). Education on Pressure Sore Development in Elderly Hospitalized Patients, 148 ARCHIVES 17. See generally THE AM. HEALTH CARE ASS'N, THE INTERNAL MED. 2241, 2243 (1988). LONG TERM CARE SURVEY (1999). 30. See Barbara Bowers & Marlon Becker, Nurse's 18. Minimum Data Set V2 User's Manual (Replica Aides in Nursing Homes: The Relationship Edition of the Official HCFA Manuscript), (Eliot Between Organization and Quality, 32 Press, Natwick, MA (1995)) (providing technical but GERONTOLOGIST 360, 364-65 (1992). essential reading for those seeking to understand the Minimum Data Set and its use in the nursing home 31. See INST. OF MED., IMPROVING THE QUALITY OF and best understood when accompanied by explana- CARE IN NURSING HOMES (1986). tion from an expert in the nursing home field). 32. See Dan R. Berlowitz et al., Are We Improving the 19. See generally AGENCY FOR HEALTH CARE POL'Y & Quality of Nursing Home Care: The Case of RESEARCH, U.S. DEP'T HEALTH & HUMAN SERVS., Pressure Ulcers, 48 J. AM. GERIATRICS SOC'Y 59, 60 PUB. No. 92-0652, TREATMENT OF PRESSURE ULCERS (2000). 50 Elder's Advisor
33. See generally FRANK B. HOBBS & B.L. DAMON, U.S. 34. See John W. Rowe et al., Academic Geriatricsfor DEP'T OF COMMERCE, ECONOMICS & STATISTICS, the Year 2000: An Institute of Medicine Report, BUREAU OF CENSUS, SIxTY-FIVE PLUS IN AMERICA, at 316 NEW ENG. J. MED. 1425, 1428 (1987). 23-190 (Current Population Reports and Special Studies, 1996).