Episode 157

Are pressure ulcers avoidable?

 

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Avoidable pressure ulcers should be a top priority for every nursing home. The term “avoidable” is defined in the Federal regulations governing the operations of nursing homes. A pressure ulcer is avoidable when a nursing homes neglect to assess a resident’s skin integrity, complete a care plan with personalized interventions based on that assessment, or update that care plan based on observation. Neither age, chronic illness, or non-compliance plays a factor. In this week’s episode, we talk about a nursing home’s obligation to residents to prevent pressure ulcers, and what it means to be avoidable or unavoidable. 

Today on the podcast, we are going to be talking about the concept of avoidable or unavoidable pressure ulcers. That is what I would call a term of art, whether or not a pressure ulcer is “avoidable,” “unavoidable,” is a term of art. It is dictated, it is defined by federal regulations that oversee nursing homes. 

Where can I learn more about preventing pressure ulcers?

But before we get specifically into that and start parsing through what all that means, I want to take a quick second to tell you what a pressure ulcer is itself. Again, I try to make these podcasts stand alone. In other words, I want to try to make these educational for a family member of a nursing home resident who needs information about their specific situation. So I try not to, as much as possible, make someone have to listen to another episode to be informed about the specific episode they might be listening. But if you want a more nuanced, a longer talk on exactly what pressure ulcers, then I would recommend you check out Episode 135, which is understanding pressure ulcer stages, Episodes 121 and 123, which deal with preventing pressure ulcers and treating them in nursing homes, pressure ulcers in nursing homes. So in those episodes, we go way full into depth on the physical properties of pressure ulcers, like how they occur, whatever, but the definition I’m about to give is a little abbreviated.

Five Ways to Prevent Pressure Ulcers in Nursing Homes

Practical Methods for Treating Pressure Ulcers in Nursing Homes

Understanding Pressure Ulcer Staging

What is a pressure ulcer?

So essentially a pressure ulcer is an injury to the body that occurs wherever there typically is a bony prominence, like a heal, the buttocks, shoulder blade, wherever there is both pressure and a bone that essentially squeezes the area between the bone and the surface of the skin. That is the typical cause of a pressure ulcer. Now there are pressure ulcers that occur because of medical equipment like tubes or physical casts, these types of things, but by and large, pressure ulcers are caused in parts of the body where there’s a bony prominence and there’s sufficient weight. Most of our cases involve heels or the buttocks.

And so what happens is that that area where the tissues and muscles are, because of the pressure and that squeeze, there is either a lack of blood flow or an impediment of that blood flow, so not enough blood is getting to that area. And after a certain amount of time without blood flow and without the oxygen and nutrients that flow in that blood, the muscle and the tissue begin to decay, a lot of times from the bottom out. So over time, the tissues in that muscle decay and die and the skin opens up, and you begin to develop essentially an open wound on the body. I mean if that is not enough to be dangerous, what typically happens is when these types of cases come to our door is that there has been some type of infection and as a result of that infection, sepsis or sometimes shock, and the person passes or as a result has to have some type of amputation or is permanently disfigured in some way from that pressure ulcer all because a particular area of the body did not get, because of pressure, adequate blood flow and therefore nutrients and oxygenated blood. That, in a nutshell, is a pressure ulcer, a pressure wound, a decubitus – well not decubitus, but an ulcer, a bedsore as it’s often called, as we often call it on this show.

What makes a nursing home resident more susceptible to pressure ulcers?

Why do we talk about pressure ulcers in nursing homes as opposed to your house or a hospital? The reason why is because the typical nursing home resident is a part of a vulnerable population. And the typical nursing home resident probably on the checklist has checked off many of the risk factors of pressure ulcer developments, and those would include impaired or decreased mobility, meaning the individual typically can’t move parts of their body either through weakness or some type of issue. So for example, we see a lot of nursing home residents who have had strokes and therefore they have paralysis of a part of their body or their whole body, or due to dementia are unable to move themselves. So immobility, decreased mobility is a strong risk factor.

What we would call comorbid conditions, comorbidities, chronic illnesses, so there are several chronic illnesses that nursing home residents, residents of long-term care have that can increase the risk of pressure ulcers. And those include thyroid disease, renal disease and diabetes. And the reason why these particular chronic illnesses affect pressure ulcer development is all of them in such a way have to deal with the transport of nutrients and oxygenated blood throughout the body. So any type of chronic illness or condition that prevents your blood from moving with the appropriate amount of oxygen and nutrients is going to put you at more of a risk of developing pressure ulcers.

There are certain medications that some nursing home residents take that increases the risk. For example, some steroids will do that. They affect in the same way that those chronic illnesses do. They affect their bodies’ ability to disperse nutrients. 

And then cognitive impairment as an overall condition, that is itself a risk factor because typically what we see with persons with cognitive impairments is they are unable to share they’re in pain. And so nursing home staff have to use nonverbal signs of pain to identify what’s going on. So those with cognitive impairments are at a higher risk for pressure ulcers.

Urinary or bladder and bowel issues can definitely increase a person’s risk, so incontinence of bowel or bladder – the reason is because that moisture and the actual contents of the incontinence really helps deteriorate the skin and really helps increase that risk.

And those nursing home residents have typically have had a pressure ulcer in the past and that increases the risk because typically if you’ve had one pressure ulcer, you’re going to get another one, and the reason is because a lot of times, the body does not heal completely the same as it was before that pressure ulcer happened, depending on how deep the wound was or how significant the original pressure ulcer was. So we are talking about pressure ulcers within the nursing home community most of the time because nursing home residents fit those characteristics of being high on the risk factor scale for developing pressure ulcers.

What are the federal regulations regarding avoidable pressure ulcers?

Okay, so what do those federal regulations say? What are the requirements, the guidelines that nursing homes need to be following or refer to when dealing with nursing home residents’ skin integrity? And that’s found at in the Code of Federal Regulations – for any lawyers out there listening, that’s 42-CFR-483.25 – that deals with skin integrity and this is what it says. “Based on the comprehensive assessment of a resident, the facility must ensure that, one, a resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable, and two, a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.”

What makes pressure ulcers avoidable?

Now the intent of that requirement is that the resident does not develop pressure ulcers unless clinically unavoidable. So what does clinically unavoidable mean? What was unavoidable mean? What does avoidable mean? Avoidable means the resident developed a pressure ulcer and that the facility did not do one or more of the following – evaluate the resident’s clinical condition and pressure ulcer risk factors, define a implement interventions that are consistent with resident needs, resident goals and recognized standards of practice, or monitor and evaluate the impact of the interventions and revise the interventions as appropriate. 

A pressure ulcer is avoidable based on the nursing home’s actions

So again, avoidable doesn’t have anything to do – unavoidable doesn’t have anything to do with the underlying conditions of the resident, the risk factors. What makes a pressure ulcer avoidable or unavoidable in the eyes of the law, in the eyes of the federal regulations, is what the nursing home does with that information, with those underlying conditions. So again, a pressure ulcer is avoidable, meaning it should not have happened, if the nursing home fails to assess the resident properly, fails to create an adequate care plan or fails to revise that care plan when it is necessary to do so. That is an avoidable pressure ulcer. Unavoidable is when even though the nursing home properly assesses the resident, properly implements the care plan and properly revises the care plan, it develops anyways. That’s an unavoidable pressure ulcer. That’s the question, that’s the $64,000 question in any of these cases. Did the nursing home assess, make a care plan and revise that care plan or not? If they failed any one of those three, it doesn’t matter what the underlying conditions are. It doesn’t matter what the comorbidities are. It does not matter the chronic illnesses. All of those things, those underlying conditions, should have been taking into account with the assessment, then blueprinted into that care plan and then revised if necessary. That’s avoidable and unavoidable.

Can you sue a nursing home?

So can you sue a nursing home for pressure ulcers? The answer is yes. The answer is yes. That is something that our firm does a considerable amount of. And we go, and if you talk to your attorney in your state and in your local area, they’re going to go to these federal regulations, they’re going to go to the typical standards of care and they’re going to go, “Okay, well if Ms. Johnson was cognitively impaired, what did they do in the care plan? If Ms. Johnson is unable to move herself, what interventions did they put in place to make sure she doesn’t stay in one place in her bed for periods of longer than necessary?” So what you’ll typically see in an assessment is some type of pressure ulcer, skin integrity risk assessment. Most of the time, that is going to be the Braden Scale, and actually we had an entire episode dedicated to the Braden Scale and pressure ulcers and skin integrity assessments with I think it was Dr. Nancy Bergstrom, who was the co-developer of the Braden Scale itself – Dr. Nancy Bergstrom. We had her on, I believe, Episode 152 – I think that’s right? Yeah, I think that’s about right. Super interesting article, very nice woman and great episode if you want to go listen to that episode and learn more about avoidable pressure ulcers. 

How does a resident assessment prevent injury? 

But anyways, there’s the assessment process. So did the nursing home take into account all of these risk factors? That’s number one. And then we look at the care plan at that point. So the care plan is often the point where things go awry and that’s where the liability really hits home because most of the time, an assessment is being done. Now we can talk about whether the assessment is appropriate or not based on how it’s done, but in my experience and I could be wrong, for any of the lawyers out there listening, if there are any lawyers out there listening, the idea that the care plan and the implementation of the care plan is typically where the liability of the nursing home happens. And that’s typically if an individual has been assessed as a high risk for a pressure ulcer development, almost always the universal precaution, the universal intervention is going to be a turn and reposition schedule that’s every two hours. So in other words, the resident would not be allowed to lay on their back all day. They would be propped on their side left to right every two hours. So every two hours, the nurse aide would come in. If they’re laying on their left, they get switched and put on their right. That’s pretty much universal. But again, that’s just an example of an intervention put in place based on an assessment. So the liability with the nursing home usually comes with the failure of implementing what’s in the care plan, so not turning and repositioning every two hours, even though the care plan says to do that, or for example, making sure the individual gets a certain level of protein every day, and you can look and see whether or not the diet the person was supposed to get has the appropriate amount of protein. There are a million things you can look at within the care plan to make sure they’re doing everything they can to prevent that pressure ulcer. In short, you cannot have avoidable pressure ulcers if the facility is conducting accurate assessments. 

How does a resident care plan prevent pressure ulcers?

And then of course it needs to be revised if necessary. And one of the things we see over and over again is you might have an okay assessment. You might have an okay care plan and everybody’s doing what they’re supposed to do under the care plan. But the individual might develop a skin issue and it’s not, the care plan is not revised based on that skin issue and that skin issue becomes a pressure ulcer and then the nursing home might be liable, but I guess what I’m saying is that the other liability component comes in if the care plan is not revised if it needs to be revised.

So I guess another example of that would be if the nursing home, despite the care that is being provided, the individual develops a pressure ulcer and then they revise that care plan and then individual develops another pressure ulcer and doesn’t do anything, that could be a problem because that represents a problem with the implementation of the care plan. So maybe the individual needs to be turned and repositioned more than every two hours. 

So again, I guess at the end of the day what I’m trying to say, and I’m bungling my way through it, is that you can sue a nursing home for pressure ulcers, but the issue is is it avoidable or unavoidable? And the answer to that is did they do these three things – assess, care plan, revise care plan? If they didn’t do even just one of those things, then the pressure ulcer is avoidable and that is potential grounds for a lawsuit. But again, nursing homes are not – this is not their first rodeo. They throw everything in the kitchen sink at you. They’re going to say, “Okay, we breached the standard of care but it wasn’t the cause of X, Y and Z. Diabetes was or the chronic condition was.” And again, you’ve got to point back to, “Nope, federal regulations say you should have taken the diabetes into account with regard to this care plan, and in fact it was avoidable, not unavoidable.”

How does a resident’s clinical condition contribute to a pressure ulcer?

So to some extent then, health factors in but health only factors in if all of the health conditions were taken into account at the assessment, the assessment was used to make a great care plan, the care plan was carried through A to Z and then it was revised when it was needed to be and there was still a pressure ulcer – that’s when there is a viable argument to be made that the clinical condition, the medical condition, the underlying diseases and chronic illnesses of your loved one are the true cause of the pressure ulcer, not the nursing home. Only then would the health of your loved one really come into play. But again, if you can prove the nursing home failed in any of those three, then it’s not unavoidable. Avoidable pressure ulcers should not be occurring in nursing homes. Why? Because assessments should be conducted, followed by a care plan, followed by revisions. 

And I think that’s all I got. I’m really – I guess, what’s the word? – beating a dead horse? Really taken this to its fullest extent here as far as I can see. So to anybody still listening, thank you. If you’re enjoying the content of these episodes, please be sure to like and subscribe wherever you get your podcasts from. And if you’re on YouTube, please be sure to like and subscribe, leave a review, leave a comment. We’d be happy to hear from you.

 


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