Pressure ulcer injury cases are one of the more common types of cases against nursing homes. Nursing home residents are particularly vulnerable to developing pressure ulcers because they are usually elderly, debilitated and depend on caregivers for normal activities of daily living such as grooming, toileting, mobility, eating, and their medical care.
A pressure ulcer, also called a bed sore, pressure wound or decubitus ulcer, is an injury to the skin and/or underlying tissue usually over a bony prominence that is caused by pressure. These ulcers develop due to prolonged pressure on the skin and when the skin is subject to other forces like friction and shear. They most often develop on skin over the bony areas of the hips, tailbone, buttocks, heels and ankles, but can also develop on other areas of the body exposed to prolonged pressure. With prolonged pressure, these areas receive inadequate blood flow, which causes the tissue to die. In combination with pressure, friction and shear forces contribute to causing these injuries. Shear occurs when two surfaces move in the opposite direction. For example, if someone is in a bed with the head of the bed elevated and they slide down, as the tailbone moves down, the skin over the tailbone may stay in place causing a shearing injury. Friction occurs when the skin rubs against bedding or clothing, which can be a problem for fragile and moist skin.
Pressure ulcer injuries can be very serious and can lead to infection, amputation and death, especially in the elderly. That is why it is particularly important to recognize those at risk for developing pressure ulcers and implement measures to prevent them from developing.
There are a number of things that may put someone at risk for developing pressure ulcers, but people most at risk are those who are unable to change positions without assistance and who spend most of their time in bed or a chair. People who are mobile and active are not at risk for developing pressure ulcers because they naturally reposition themselves when they start feeling discomfort, which relieves the pressure and allows the tissues to receive adequate blood flow. Nursing home residents typically have limitations and conditions that put them at higher risk for developing pressure ulcers. Some of these risk factors include:
- Advanced age
- Immobility (wheelchair or chair bound)
- Need of assistance to move or change position
- Lack of Sensory Perception (an inability to feel pain or discomfort that inhibits the awareness to realize a position change is needed)
- Poor nutrition (people need enough calories, vitamins, protein, minerals to maintain healthy skin and prevent tissue breakdown)
- Poor hydration
- Incontinence
- Medical conditions affecting blood flow (diabetes and vascular disease)
- Mental deficits (dementia/Alzheimer’s)
Assessing the resident’s risk for pressure ulcers and implementing interventions to prevent pressure ulcers from developing are key for pressure wound prevention. Nursing homes are required to conduct a head-to-toe skin assessment upon the resident’s admission, readmission, and throughout their admission. The head-to-toe skin assessment should document whether the resident has any existing wounds or skin breakdown. If skin breakdown is present, the skin breakdown should be further assessed and treated.
In addition to assessing whether the resident has existing skin breakdown or pressure ulcers, the nursing home should assess the resident’s risk of skin breakdown. One of the most widely used risk assessment tools is the Braden Scale for Predicting Pressure Sore Risk. This scale allows nurses and other healthcare providers to score a person’s level of risk for developing pressure ulcers by assessing six subscales: (1) Sensory Perception; (2) Moisture; (3) Activity; (4) Mobility; (5) Nutrition; (6) Friction and Shear. The goal of the assessment is to determine the resident’s risk level of developing pressure ulcers, and to implement appropriate nursing interventions to minimize the risk. The lower the Braden score (higher the risk), the more intense the nursing interventions should be to prevent pressure wounds.
The nursing home should develop a care plan that lists the interventions that will be utilized to minimize the resident’s risk for developing pressure ulcers. The care plan is the documented plan of care that specifies how the nursing home will meet the resident’s needs and provide appropriate care. The prevention and care of pressure ulcers requires an interdisciplinary care team involving nursing, nutrition, and rehabilitation, and the care plan should address each of these care areas for residents at risk for pressure ulcers. All of these areas should be addressed in the resident’s care plan.
The various types of pressure ulcer interventions that may be appropriate for a resident’s care plan include:
- Turning and repositioning [minimum of every 2 hours]
- Support surfaces on bed and chairs [pressure reducing mattresses and cushions]
- Use of positioning devices [wedges, pillows]
- Elevate heels off bed
- Keep skin clean and dry
- Cleanse skin at time of soiling
- Protective moisture barrier
- Active and passive range of motion exercises
- Left sheets or lift equipment to reposition or transfer resident
- Refer to dietitian for nutritional assessment and interventions
- Maintain head of bed at or below 30 degrees, if consistent with resident’s medical condition
- Report weight loss, poor appetite or gastrointestinal changes that interfere with eating
When a resident develops a pressure ulcer, the nursing home should notify the physician as well as the resident’s family/responsible party. The nursing home should have a documented assessment of the pressure ulcer, new interventions on the care plan to address the new pressure ulcer, and ongoing reassessments of the pressure ulcer and the effectiveness of the interventions.
In this vulnerable population, prevention and early intervention is key! If you would like to speak with experienced nursing home attorneys who pursue cases against nursing homes in the Atlanta metro area and throughout Georgia, call Gretchen Wagner or Kate Hughes at the law firm of Wagner Hughes, LLC. This consultation is free and you will speak directly with a senior attorney.
