Jonathan Rosenfeld's Nursing Homes Abuse Blog : Jonathan Rosenfeld's Nursing Homes Abuse Blog | Lawyer & Attorney : Strellis & Field Law Firm | Bed Sores, Senior Neglect, Elder Abuse, Sexual Abuse: Chicago, Illinois

Some of my angriest clients contact me after a loved one was transferred from a nursing home to another nursing home or hospital only to learn of serious medical problems their loved one likely acquired during their original admission.  

Of course, breaking disappointing news is difficult for anyone to do.  Yet, in the case of nursing homes-- this is something they simply are required to do under the law.  Similarly, nursing homes must notify the patients doctor if their condition deteriorates.

I see many cases where there is no doubt an intention on the part of the original facility to cover up change in condition-- but also injuries related to situations involving improper care.

This situation of a dangerous condition being discovered only after the patient was transferred to a hospital was highlighted in a recent lawsuit filed against an Illinois Nursing Home, Alhambra Care Center.  Part of the lawsuit alleges that the patient lived that the nursing home with multiple health problems, but the staff at the facility failed to notify the family of the conditions including:

• Stage III decubitus ulcer
• Multiple stage I and II decubitus ulcers on the patients feet
• Dehydration
• Urinary tract infection

None of the conditions were disclosed to the family until after the patient was admitted to a local hospital.  

In cases such as these-- perhaps more alarming than not notifying the patients family as the various problems their loved one has developed-- is the fact that the facility allowed the conditions to develop in the first place.  My guess is that the facility was so ashamed of the condition they allowed their patient to get into that they failed to document the conditions during the patients stay at the facility either.

Some of these situations may give way to a claim against the nursing home where the condition developed.  In addition to contacting an attorney to discuss your legal options, you should give serious consideration to locating another facility for your loved one following their discharge from the hospital.

Related:

Dehydration & The Development Of Bed Sores In Nursing Home And Hospital Patients

Untreated Urinary Tract Infections In Nursing Home Patients May Result In Urosepsis

Why do nursing homes describe pressure sores according to 'stages'?

Are bed sores on the heels common? Bed Sore FAQ

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An article published in the Las Vegas Sun, painted an unfortunately common set of circumstances; an overweight patient goes into a hospital for a medical procedure-- only to acquire pressure sores during their stay.  Sure, the same scenario can (and most certainly does) occur with people of average stature, but there definitely is a disproportionate number of obese patients who enter a hospital or nursing home only to develop a lingering souvenir.

The sun article concentrates on 60-year-old Tyrone Bush, a maintenance man, who was admitted to Desert Springs Hospital for a quadruple heart bypass surgery in 2008.  It was during Bush's recovery at the hospital, that he developed multiple bed sores (or pressure sores, pressure ulcers, decubitus ulcers) on his buttocks. 

More than two years later, Mr. Bush continues to be plagued from the wounds and requires extensive medical treatment for them including doctors visits and debridement procedures-- where the dead skin is removed to allow the new skin to grow over the open wounds.

Not surprisingly, the hospital where the wounds developed blames the wounds on Mr. Bush himself, implying that the wounds were unpreventable given his size.

Large Patients & The Development Of Bed Sores

Let's face it, obesity is an epidemic.  By some accounts, more than 40% of the adult population is obese.  However, the same preventative techniques for 'average' patients most definitely applies to their larger counterparts.

Regular relief of pressure for the body is the most important preventative measure to prevent development of bed sores in all patients-- particularly the immobile.  When it comes to a larger patient, simply saying the patient is too big to move is not appropriate.  Rather, if one person can not safely move the patient, two, three or even four staff members should be summoned for assistance.

Related:

What can hospitals do to reduce the rate of bed sores in their facilities?

What is ‘turning’ and why is it important to prevention of bed sores?

If a lawsuit or claim is filed against a facility where a person developed bed sores, what type of damages is the person entitled to?

Where can I learn more about the laws applicable to people who develop bed sores in nursing homes or hospitals?

Bed Sores, Nursing Home Injury Laws

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One of the most memorable cases I worked on involved a young man who was in a nursing home following a severe injuries he sustained in a construction accident.  Due to the nature of the man's injuries, a catheter was used to drain urine from his bladder.  Despite doctors orders to change the catheter every 30 days, months went by without any catheter change.  In fact, six months went by without a catheter change.

Finally, after six months without a catheter change, a nursing home employee recognized the obvious problems: cloudy / brownish urine and testicles extremely swollen due to infection.  The situation initially resulted in a hospitalization where the man's testicles were surgically removed.  Unfortunately, the staff's intervention was too little, too late.  Within a week of arriving at the hospital, the man died from a condition known as urosepsis.

Urinary Tract Infections

Urinary Tract Infections (UTIs) seem like a minor problem, especially in nursing homes, considering the range of common diseases, infections, and illnesses. However, UTIs can prove very dangerous, especially when nursing home facilities fail to prevent UTIs in the first place or fail to provide proper and prompt treatment.

Urosepsis

Urosepsis is basically a severe urinary-tract infection. A UTI occurs when bacteria travels up the urethra (the opening in the body through which urine passes) into the bladder. UITs account for over 30% of infections reported by acute care hospitals and are the most common type of healthcare-associated infection. 

The bacteria can stay contained in the bladder (cystitis), travel to the kidneys (pyelonephritis), or even spread into the bloodstream (urosepsis). With urosepsis, you can suffer a dangerous drop in blood pressure, which can deprive your organs of oxygen. It can even prove fatal if you do not receive prompt antibiotic therapy, with an associated problem of increased use of antibiotics and multidrug-resistant bacteria.

Symptoms of UTIs include:

• Strong, persistent urge to urinate
• Burning sensation when urinating
• Passing frequent, small amounts of urine
• Blood in urine
• Cloudy, strong-smelling urine
• Bacteria in urine

More severe UTIs can also cause the following symptoms:

• Flank (upper back and side) pain
• Lower abdomen pain
• Fever
• Shaking and chills
• Nausea
• Vomiting
• Frequent, painful urination

While most urinary infections are mild, they can progress to more serious infections. Risk factors for urosepsis include:

• Older age
• Being female
• Having an indwelling urinary catheter (Foley catheter)
• Suffering from kidney stones
• Having impaired immunity

Urosepsis and catheter usage

UTIs are a common problem for the elderly because they are more likely to suffer from common risk factors. There is a marked increase in the prevalence of UTIs in both women and men after age 65. Females are more likely to suffer from UTIs as they age because of physiology and hormone changes. 

First, women have a shorter urethra, making it easier for bacteria to travel into the bladder. Second, as women age because the tissues of the vagina, urethra, and base of the bladder become thinner and more fragile. In addition, decreased estrogen levels causes pH changes in the vagina, allowing E.coli colonization, which causes about 80% of all UTIs. Men, on the other hand, suffer more UTIs when older because of prostatic disease. 

Risk factors include:

• Atrophic urethritis
• Atrophic vaginal mucosa (atrophic vaginitis)
• Benign prostatic hyperplasia
• Prostate cancer
• Catheter use
• Chronic bacterial prostatitis
• Genitourinary abnormalities
• Genitourinary calculi
• Renal and perinephric abscess formation
• Urinary diversion procedures
• Urethral strictures

Improperly maintained catheters are one frequent cause of UTIs. Usually, the longer a catheter is in place, the more likely an infection will develop. Up to 35% of patients requiring a urinary catheter for seven days or more will develop a CAUTI. About 50,000 long-term care residents have catheters at any given time according to the CDC’s 2009 report on catheter-associated urinary tract infections (CAUTIs). 

It is recommended that catheters are used only in appropriate situations and are left in place only as long as necessary. (See “Never Event #4: Catheter Associated Urinary Tract Infections and Nursing Homes Abuse Blog: Catheter Usage)

There are steps that nursing homes can take in order to reduce the risk of CAUTIs (proper use, proper technique, and proper situations). Proper use of urinary catheters is important, including:

• Not using urinary catheters to manage incontinence
• Using urinary catheters only in patients as necessary
• Remove the catheter as soon as possible
• Not using urinary catheters as a means of obtaining urine for culture or other diagnostic tests when the resident can voluntarily void

Instead, urinary catheters should only be used when necessary. Situations where indwelling urethral catheters are appropriate include: 

• When resident has a bladder obstruction
• Critically ill patient cannot voluntarily void urine for tests or to measure urine output
• Patients undergoing urologic surgery
• To help genital or anal wounds heal
• If resident requires prolonged immobilization
• To improve comfort for end of life care

Proper technique for urinary catheter insertion can also help reduce the risk of CAUTIs including:

• Washing hands before and after inserting or touching the catheter or catheter area
• Ensuring that only properly trained professionals insert/maintain the catheter
• Only touch the catheter when necessary
• Use sterile equipment
• Ensuring that healthcare personnel who take care of catheters receive periodic in-service-training

If used properly (proper situation and proper technique), indwelling urinary catheters can be a helpful tool when caring for nursing home residents. However, when proper technique, use, and care of catheters are not achieved, serious bacterial infections can occur.  

It is frightening how quickly a simple UTI can turn into a dangerous bacteria infection (urosepsis) that could prove fatal. Bloodstream infections in the elderly are associated with a higher mortality rate compared to bloodstream infections in younger age groups. Therefore, prevention of dangerous UTIs and proper treatment is important. 

If you or a family member has an indwelling catheter, it is important to ask questions about why it is necessary, for how long it is necessary, and proper and hygienic care. 

Thanks to Heather Keil, J.D. for her assistance with this Nursing Homes Abuse Blog Entry

Sources:

Nursing Homes Abuse Blog: Never Event #4: Catheter Associated Urinary Tract Infections

Nursing Homes Abuse Blog: Catheter Usage

CDC: Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009

The Merck Manual of Geriatrics: Urinary Tract Infections

Geriontological Nursing: Urinary Tract Infection - Guidelines to assessment, treatment, and prevention in the older adult

The American Journal of Medicine: Bloodstream infections in the elderly

International Journal of Experimental, Clinical, Behavioural, Regenerative and Technological Gerontology: Unique Aspects of Urinary Tract Infection in the Geriatric Population

Journal of the National Medical Association: Problems in diagnosing infections in the elderly

The Journal of Urology: Chronic indwelling catheter replacement before antimicrobial therapy for symptomatic urinary tract infection

Emerging Infectious Disease Journal: Engineering out the risk for infection with urinary catheters

Journal of the American Medical Directors Association: Complications of chronic indwelling urinary catheters

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Today marks the 6th entry in the collaborative series I am doing with David Terry regarding the Six Common Causes of Bed Sore & What Caregivers Can Do To Improve Care.  For this final entry David addresses the use of pressure relieving devices to combat the development of bed sores.

As a lawyer who sees a significant number of cases where nursing home or hospital patients have developed bed sores (also referred to as: pressure sores, pressure ulcers or decubitus ulcers) during a short or long-term admission, I feel as though the most progress has been made with respect to new technology in the utilization of pressure relieving devices.

As David points out, special padding on wheelchairs, heel pads and pressure relieving mattresses are the most common types of pressure relieving devices used in nursing homes and hospitals. Like all medical devices however, to achieve maximum benefit from the new technology staff must receive proper training.

Occasionally, we see long delays between the implementation of the pressure relieving devices from the time that they were originally ordered by the doctor.  Sometimes the delay is based on the fact that the facility may be inadequately stocked with the devices.  Yet in other situations, facilities may claim that such devices are too expensive. 

Unfortunately, given the alternative-- having patients with advanced bed sores, the reality is that these devices are a bargain from both a cost savings standpoint in terms of bed sore treatment expenses as well as the physical and psychological toll bed sores take on patients.

Related:

Why do some wound clinics and nursing homes suggest the use of Clinitron beds for patients with bed sores?

Are pressure relieving mattresses required to be used in nursing homes?

Are bed sores on the heels common?

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The underlying mechanics behind the development of bed sores (also called: pressure sores, pressure ulcers or decubitus ulcers) is relatively simple-- unrelieved pressure on the body results in restricted blood circulation and consequential lack of nutrients and oxygen to skin and tissue.  When pressure goes unrelieved for extended periods of time, tissue dies and a wound develops in the area.

Armed with a basic understanding of the mechanics behind the development of bed sores, medical professionals suggest alleviating the pressure on the body on regular intervals. 

If a patient is mobile, they should be encouraged to get active on a regular basis. Obviously, for physically incapacitated patients who are unable to move on their own, staff assistance is necessary to relieve pressure. 

In today's series on causes of bed sores and how caregivers can prevent them in conjunction with David Terry, I am going to discuss the most widely accepted method of preventing bed sores -- turning.

What is turning and why is it necessary?

'Turning’ refers to exactly what it sounds like– turning the patient to prevent the build-up of pressure on the skin that can result in the development of bed sores. Turning is universally considered to be the most important factor in bed sore prevention. Yet, despite its universal acceptance, many facilities (hospitals and nursing homes) fail to properly implement turning techniques– it is hard, labor-intensive work.

Turning should be completed at intervals set forth by a physician. However, turning of patients at least every two hours is usually considered to be the minimally accepted interval. In bed-bound residents, the staff should rotate the patient to their sides. In residents who spend most of their time in wheelchairs, staff need to lift the residents out of their chairs.

Caregiver tip:

Caregivers need to recognize the importance of relieving pressure on a regular basis and be on the look-out for facilities that make rotating patients a priority.  Many nursing homes that incorporate facility-wide turning programs have:

• Charts in all patient rooms to help staff keep track of patient positioning in bed
• Have regularly scheduled music to remind patients and staff to change position
• Provide additional staff for assistance with rotating patients
• Dim lights on regular basis to remind staff and patients of turning interval

Similarly, if you don't see any of the above indications that the nursing home your loved one is ask, don't be afraid to ask the staff or administrators about the facilities bed sore prevention program.  As I see over and over again, patients tend to receive better care when they have an advocate looking out for their best interest.

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Today, David Terry has a great entry on his Nursing Home Abuse Blog regarding contractures and the development of bed sores.  

Contractures are a medical condition where a joint is held in a fixed position due to the shortening of a muscle or tendon due to stress exerted on the muscle or spasticity (uncontrolled muscle movement). Older patients and those with limited mobility are especially prone to develop contractures. Contractures most commonly form in:

• Hands
• Feet
• Arms
• Legs

Once an individual has developed contractures, little can be done to alleviate the problem aside from aggressive orthopedic surgery. Consequently, medical facilities (hospitals and nursing homes) should provide physical and occupational therapy to people who are at risk for developing contractures and to keep the body flexible.

Once a person has developed contractures they are at a heightened risk for developing bed sores due to their bodies limited ability to move– with or without assistance and the unnatural pressure put on the body in a rigid state.

The rigidity that accompanies contractures generally means that many of the repositioning techniques commonly used to prevent bed sores may be unfeasible. As a general rule, the more immobile an individual is, the higher likelihood they have in developing bed sores.

The duty of nursing homes to prevent bed sores

Contractures simply are not part of the aging process!  Recognizing the problems associated with contractions and the fact they remain widely preventable, federal law requires facilities to take action to prevent contractures.  The applicable law, 42 CFR §483.25(e)(2) states:

"Based on the comprehensive assessment of a resident, the facility must ensure
that -- A resident with a limited range of motion receives appropriate treatment and
services to increase range of motion and/or to prevent further decrease in range of
motion."

Caregiver's tip for preventing contractures:

David Terry has some practical suggestions for preventing contractures in bed sore patients.  Here's are David's suggestions.

• Insist that your loved one receive stretching exercises twice daily.
• Insist that all necessary preventive devices are used.
• Visit often and make sure that staff members are attentive to the needs of your loved one.
• Be respectful, but firm that your loved one receives the care they deserve.

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Today's portion of my ongoing series with attorney David Terry regarding bed sore causes and how caregivers can prevent them, deals with an embarrassing-- yet commonly encountered condition amongst nursing home patients-- incontinence.

Like many other medical complications facing nursing home patients, the source of the problem typically stems from staffing.  Improperly trained staff or simply inadequate man power are usually the underlying reasons why patients sit in soiled clothing or diapers for extended periods of time.  

Incontinence and developing bed sores

There are a variety of psysical and psychological reasons why a patient may be unable to control their bladder or bowel.  Despite the underlying reasons for fecal or urinary incontinence, the fact remains that incontinent nursing home patients are at a heightened risk for developing bed sores (also referred to as: pressure sores, pressure ulcers or decubitus ulcers) compared with their continent peers.

When urine and fecal matter remain in contact with the delicate skin on the buttocks and genitalia, the caustic nature of the waste exacerbates the skin-breakdown.  When urine or feces is left uncleaned for extended periods, it results in rapid breakdown of the skin especially in bed-bound patients who sit in bed for extended periods.

Incontinence and exacerbation of existing bed sores

Should a bed sore develop in an incontinent patient, staff must be extra diligent to keep the patient clean and dry. In cases where a patient has an open wound (stage 3 or 4), the wound provides easy-access for bacteria to enter the body.  Bacteria in feces can enter the wounds causing serious infections such as sepsis-- a systematic infection that can enter the body through and open wound and spread though the blood.

In some cases involving incontinent patients with severe bed sores on the buttocks or sacrum, a physician may recommend a surgical procedure to prevent fecal material getting into the wounds and causing further complications.  A surgical procedure known as a ‘colostomy’ or ’diverting colostomy’ to divert fecal waste into a pouch as opposed to passing through the rectum.

During a colostomy procedure, surgeons cutting the colon into a shorter piece and bringing it through the wall of the abdomen. A colostomy bag is attached to the end of the colon exiting the abdomen where fecal material is collected. The end of the colon that leads to the rectum is closed off and becomes dormant.  After the wound has healed and the colostomy bag is no longer needed, the procedure may be reversed.

Caregiver tips for incontinent patients:

As a caregiver, knowing the potential risks that accompany many medical conditions is perhaps the most important aspect of preventing further complications.  Keep in the mind the following when caring for an incontinent patient.

• If you know your patient is wet, demand the facility clean and change them immediately
• Encourage patients who are capable of using the toilet to do so
• Keep call buttons within reach of patients so they may notify staff when they require attention
• As soon a pressure sore becomes noticeable (stage 1) apply barrier gels and bring the condition to the attention of the patients physician

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It appears even in idyllic Idaho, pressure sores are a tremendous problem facing nursing home patients.  As attorney John Kormanik discusses in his recent Nursing Home Abuse Advocate Blog entry,  Idaho Facilities Cited For Failing To Prevent Pressure Sores, a staggering 40.5% of Idaho Nursing Homes were cited for violations relating to improper patient care.

As John points out, pressure sores or decubitus ulcers / pressure ulcers / pressure sores can be prevented with relatively simple techniques such as turning patients on a regular basis to reduce the formation of pressure on the body.  

David Terry and I will address turning and repositioning in our upcoming exchange and I look forward to hearing from John regarding his experience with this commonly known preventative technique.

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Sad but true, many nursing home patients are suffering from malnutrition.  While we often associate malnutrition amongst the homeless or people living in a third-world country, some studies suggest that between 35% and 85% of nursing home patients are malnourished.

As attorney David Terry points out in his blog post, "How Does Poor Nutrition Affect the Development of Bed Sores in Nursing Homes?" the rampant malnutrition can be associated with an increased risk of developing bed sores.

Poor nutrition results in a deterioration of body functioning.  Over extended period of time, patients without adequate nutrition tend to have organs that begin to fail and critical body functions begin to deteriorate and lose effectiveness.

As the largest organ of the body, your skin is one of the first places where the consequences of inadequate nutrition may be visible.  Malnutrition can result in the deminished effectiveness of the skin's natural resiliance to pressure and other factions that contribute to the development of bed sores (similarly described as pressure sores, pressure ulcers, or decubitus ulcers).

In addition to malnutritions reduction in the effectiveness in the skins natural resilancy, malnourishment of nursing home patients may also lead to other medical problems that contribute to the development of bed sores:

Reduction in Energy Levels: Malnourished people have less energy and consequently are unable to move on their own– resulting in a more time spent in one position.

Reduction in the bodies natural cushioning: A long-term consequence of malnourishment is loss of fat, muscle and tissue– that provide necessary padding particularly in bed-bound patients, the less padding the more pressure that is put directly on the body– thereby resulting in increased rate of bed sores.

Inadequate Nutrition & Hinderance of The Bodies Natural Healing Properties

David makes a great point regarding the important role nutrition plays in not just bed sore prevention, but also healing bed sores.  One of the most overlooked aspects of bed sore treatment is assuring that facilities provide additional calories and protiien for patients with advanced bed sores.

A nutritional consultation should be brought in for patients with open wounds (stage 3 or 4 bed sores) so the specific nutritional needs can be tailored to the patient need. 

Caregiver tip:

As family and caregivers it is important to recognize the severity of the medical complications that accompany malnutrtion.  As with many medical conditions, it is far easier to prevent malnutrition than to teat the accompanying medical complications that tend to develop over time.

Caregivers should be on the lookout for the following: 

• Look out for physical signs of malnutrition: diarrhea, disorientation, drastic weight loss, reduced urine output or cracking skin
• Request a speech tharapist consult if your patient has difficulty swallowing 
• For bed bound patients, make sure meals are within reach of the patient and there is staff present to assist
• Ask about nutritional supplements for patients who are weak or have exhisting bed sores

Related Bed Sore FAQ's:

Can malnutrition cause bed sores?

Are the development of bed sores during a nursing home admission an indication of nursing home neglect?

Extra Calories Essential For Pressure Sore Patients To Heal Wounds

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In the first part of my collaborative series with attorney David Terry, I will address the relation of dehydration with the development of bed sores (or pressure sores, pressure ulcer or decubitus ulcers-- whatever you prefer to call them).

Simply put: dehydration occurs when a person does not receive enough liquids though eating, drinking or through mechanical intervention such as intravenous fluids or a feeding tube to maintain their optimal physical functioning. When the body is deprived to fluid intake, imbalances in the bodies chemistry occur and there is a reduction of blood volume.

Alterations in blood chemistry and reduction in blood volume interfere with essential circulatory issues.  As the volume of blood in the body gets reduced, the life sustaining properties of blood to skin and tissue gets reduced. 

Without the life sustaining components a properly operating circulatory system provides-- tissues, particularly those under pressure from a person's body weight begin to die.  

Particularly in the physically disabled or bed bound, pressure tends to build on areas of the body literally supporting the persons body weight: the buttocks, sacrum or heels. When the reduced physical capability couples with the increase in pressure on areas of the body, bed sores are more likely to occur.

How to ensure your loved one is getting enough fluid?

Only a medical professional can realistically determine what each patient’s fluid intake requires after analyzing the person's body weigh and fluid output.  However, a commonly agreed upon starting point for optimal hydration is 1,500 to 2,000 ml (six to eight glasses) of fluid per day-- minimum.

Therefore, as a caregiver or just a concerned friend or family member, it is important to recognize that hydration needs and realize the hydration plays a critical role in general well-being and reducing bed sores amongst patients in a nursing home or hospital setting.  Consequently, be on the lookout for symptoms of potential dehydration including:

• Sunken eyes
• Cracked lips
• Ashen skin
• Rapid decline in cognitive function
• Chills
• Dark colored urine
• Overall physical weakness

When you visit check to:

• Ensure fluids are within reach of the patient
• Make sure the patient is capable of consuming the fluids-- straw, handled cup, ect.
• Address hydration needs with an attending physician or nurses-- particularly if the patient is incapacitated or in a coma
• Always keep a glass of water or juice on the night stand when you leave

Related:

Can dehydration contribute to the development of bed sores?

Seems Like Common Sense, Yet Many Medical Facilities Continue To Ignore Patients Daily Hydration Needs

Dehydration Leads To Lawsuit Against Minnesota Nursing Home

Nursing Home Fined In Dehydration Death

Are the development of bed sores during a nursing home admission an indication of nursing home neglect?

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Next week attorney David Terry and I will be exchanging blog-posts on perhaps the most common-- yet under-appreciated medical condition effecting patients in nursing homes and hospital-- Bed Sores.

Used interchangeably with the terms: pressure sore, pressure ulcer or decubitus ulcer, most people have little appreciation of the real devastation that bed sores cause until they see one first hand. Few medical conditions are as graphically disturbing as an advanced bed sore on a human being.

To assist medical professionals in the assessment and treatment of wounds, a standardized 'staging system' has been developed. 

• Stage 1- Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.

• Stage 2- At this point, some skin loss has already occurred — either in the epidermis, the outermost layer of skin, in the dermis, the skin’s deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.

• Stage 3- By the time a pressure ulcer reaches this stage, it has extended through all the skin layers down to the muscle, damaging or destroying the affected tissue and creating a deep, crater-like wound.

• Stage 4- In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections. If you use a wheelchair, you’re most likely to develop a pressure sore on: Your tailbone or buttocks Your shoulder blades and spine The backs of your arms and legs where they rest against the chair When you’re bed-bound, pressure sores can occur in any of these areas: The back or sides of your head The rims of your ears Your shoulders or shoulder blades Your hip bones, lower back or tailbone The backs or sides of your knees, heels, ankles and toes.

• Unstageable- Is a term that generally refers to an extremely advanced wound where there is involvement of skin, muscle and bone.

Though commonly associated with the elderly, a bed sore can develop in patients of any age who are not properly cared for.  Put simply, bed sores are not a normal part of the aging process nor are they an inevitable part of life for patients in a long-term care setting.

Unlike many medical conditions that benefit from technological advances with respect to their prevention, bed sore prevention is low-tech and labor-intensive.  To minimize the development of bed sores, medical facility staff must pay attention to patient needs, utilize patience when caring for the patient and remain diligent when implementing care.  David and I will focus our attention on the most common contributing factors to the development of bed sores:

• Dehydration
• Nutrition
• Lack of pressure relieving devices
• Turning and repositioning of patients
• Contractures
• Incontinence / cleanliness

I look forward to this exchange and particularly to David's insights on these topics.  Follow our exchange on my Nursing Homes Abuse Blog or on David's Terry Law Firm Nursing Home Abuse Blog.

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I am thrilled to announce the unveiling of the latest addition to the Bed Sore FAQ site, the Bed Sore Resource Center.  The Bed Sore Resource Center promises to become an essential tool for patients dealing with the multifaceted problems that accompany bed sores. 

Currently, the Bed Sore Resource Center has a: bed sore glossary, articles regarding bed sores, web resources providing medical and legal information pertaining to bed sores. 

Perhaps the most useful aspect of the Bed Sore Resource Center is a national directory of wound care specialists organized by state.  Currently, we have the largest centralized wound care database on the web, with more than 700 wound care professionals listed.

Check back in the upcoming months as we add even more sections to the Bed Sore Resource Center.

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Well, according to a Tennessee jury, the answer to the above question is a resounding 'yes'!  Evidence was presented to the jury regarding the circumstances that led up to the death of a resident at Celebration Way, a Tennessee assisted living facility in 2004 due to an intestinal obstruction and sepsis.

Among the claims presented by the family of the deceased was that the facility was so understaffed that they could not provide adequate care for the woman.  This claim was substantiated at the trial against the facility when it was demonstrated that despite orders for 60 doses of MiraLax, a laxative, the facility administered just 16 doses in the months leading up to the woman's death.

After a two week trial, the jury awarded substantial damages to the woman's family against: the administrator of the facility, director of nursing, Americare Systems, Inc., Shelbyville Residential LLC and Celebration Way.

Read more about this wrongful death lawsuit against an assisted living facility here.

Understaffed Nursing Homes

As lawyers who tend to see the results of things gone bad, I can attest to the problems under-staffing results in.  In some situations, staff are responsible for caring for more than 30 patients per day.  When the stresses put on nurses reach this level it is essentially impossible for them to adequately perform their job. 

Corners begin to get cut.  Not necessarily out of maliciousness or laziness-- but because there simply is not enough time in the day to perform the tasks they are responsible for.  The end result is that patients to not get the care they require and consequently get neglected or hurt.

In most situations, I point blame at the management who make a conscious decision everyday to strip staffing levels to the bare-bones in order to maximize the profitability of their facilities.  Hopefully, when courageous juries, like the one above, start sending messages in the form of large verdicts, operators will begin to change the way they do business.

Related:

Early Detection Is The Key Element To Successful Sepsis Treatment

Failure To Monitor Bowel Movements In Nursing Home Patients Can Lead To Impacted Bowels

High Staff Turnover Rates Plague Most Nursing Homes

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If you are a wound care professional with experience treating decubitus ulcers, please send me your information for addition to a new area of our sister website, Bed Sore FAQ.  Bed Sore FAQ is a compilation of commonly asked medical and legal questions regarding bed sore care and the corresponding legal rights of those who may have developed a wound during an admission to a nursing home or hospital.

Updated regularly, here is a sampling of the topics discussed at Bed Sore FAQ: prevention, treatment, research, stages of bed sores, debridement, sepsis, infection and lawsuits.

We are in the process of compiling a national database of doctors, nurses and medical facilities that concentrate in wound care. If you are interested or know of a colleague who is, kindly forward me the following information:

• NAME:
• FACILITY:
• ADDRESS:
• TELEPHONE:
• FAX:
• WEBSITE:
• AREA OF CONCENTRATION:

Bed Sore FAQ is an established resource for families and individuals suffering from bed sores. Getting quality and prompt medical attention for bed sore treatment not only improves the quality of life, but also saves lives.  In the spirit of assisting those in need, we invite wound care professionals to participate in our new endeavor to make quality wound care more accessible.

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My guess is that you'd be hard pressed to find any person-- out of all the people admitted to hospitals this very day-- who is aware of the fact that they are at an increased risk for developing  pressure sores based on the very fact that they are in the hospital.

Pressure sores acquired during a hospitalization are one of the most devastating problems facing patients in all demographics and with various types of conditions. The fact remains that thousands of hospital patients will develop a pressure sore during their hospitalization this year.  

This is not a new trend.   Rather hospital acquired pressure sores have long been a problem facing the young and old during the time they spend in hospitals.  However, unlike other medical complications that have been addressed over the past decade, pressure sores related to a hospitalization remain an untamed dragon. 

The most recent study on medical errors related to hospitalizations, the seventh annual HealthGrades Patient Study in American Hospitals should convince any skeptics out there that pressure sores (also referred to as: bed sores, pressure sores or pressure ulcers) acquired during a hospitalization are a real-- and growing problem.

In making this determination, the study evaluated medical records from 39.5 million hospitalizations at 5,000 hospitals across the country based on standards set forth by the Agency for Healthcare Research and Quality.  The studies findings indicate:

• Pressure sores are the second most common patient safety incident with a development rate of 36.05 incidents out of every 1,000 hospitalizations
• Medical treatment related to treatment of hospital-acquired pressure sores results in $2.64 billion in costs

So what does this study really tell us?

Pressure sores are not just a problem facing nursing home patients.  Hospitals must acknowledge the fact that pressure sores are a real threat to patient well-being and train staff regarding early identification and treatment.  

My hope is that by by focusing more attention on pressure sore prevention, future hospital patients can avoid the pain, embarrassment and risk associated with this ailment.

Pressure Sores Are Preventable

When high-risk patients are properly identified and preventative measure such as: regular turning, personal care, nutrition and pressure relieving mattresses are provided, the incidence of pressure sores acquired during a hospitalization can be minimized.  

It's not just me claiming this!  Medicare has placed hospital-based pressure sores on its 'never list' -- its list of medical errors that are so easily preventable that they should never happen.  No longer can hospitals seek reimbursement from Medicare for pressure sore related medical treatment if the wound developed during an admission to their facility.

Related Nursing Homes Abuse Blog Entries:

Pressure Sores In Hospitals On The Rise

Over 500,000 Adults Suffer From Bed Sores In Hospitals

Reducing Decubitus Ulcers In Hospitals. How One Facility Managed To Reduce Hospital-Acquired Wounds By 63%

Bed Sore FAQ:

How many hospital patients suffer from bed sores?

What can hospitals do to reduce the rate of bed sores in their facilities?

Are hospital patients prone to develop bed sores?

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After working on many cases involving the development of pressure sores in a nursing home or other long term care settings, I am convinced that contractures are a tremendously under-appreciated threat to patient health.  Like many ailments, we are now learning that getting older should not necessarily mean developing disabling conditions such as contractures-  with the proper nursing care.

What are contractures?

Contractures are a medical condition where a joint is held in a fixed position (frozen joints) due to the shortening of a muscle or tendon due to stress exerted on the muscle or spasticity (uncontrolled muscle movement). Older patients and those with limited mobility are especially prone to develop contractures. Contractures most commonly form in the: hands, feet, arms and legs.

How can contractures be treated?

Once an individual has developed contractures, little can be done to alleviate the problem aside from aggressive orthopedic surgery. Consequently, medical facilities (hospitals and nursing homes) should provide physical and occupational therapy to people who are at risk for developing contractures and to keep the body flexible.

Complications associated with contractures

Once a person has developed contractures they are at a heightened risk for developing bed sores (similarly referred to as decubitus ulcers, pressure ulcers or pressure sores) due to their bodies limited ability to move-- with or without assistance. The rigidity that accompanies contractures generally means that many of the repositioning techniques commonly used to prevent bed sores may be difficult to implement. As a general rule, the more immobile an individual is, the higher likelihood they have in developing bed sores.

Patients with contractures are also at risk for falls and being mishandled by staff as the rigid limbs can make daily rituals such as bathing, transferring to and from bed or wheelchair more difficult.  Consequently, facilities should use additional care, such as extra staff or lifting devices, when handling patients with contractures.

Related:

If a person has contractures, are they at an increased liklihood for developing bed sores?

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As a nursing home lawyer who has been involved in many cases where where 'sepsis' is listed as a cause of death, I can attest to the devastating effects this complication has on patients with bed sores (similarly called: pressure sores, pressure ulcers or decubitus ulcers) and other medical conditions. 

To those unfamiliar with sepsis, it is a severe infection that effects the complete body.

The wide-reaching effects of sepsis surprised even me.  According to statistical analysis of septic hospital patients:

• Sepsis is the 10th leading cause of death in the U.S.
• 1/3 of people who develop sepsis will die
• Sepsis results in more than $17 billion in medical expenses every year

The fight against sepsis has now begun!

The Banner Desert Medical Center, is now the first medical center in the country to implement a sepsis detection program to help improve the survival rate of patients.  The hospital uses a scientific formula to detect warning signs that are indicative of sepsis including:

• changes in body temperature
• increases in heart rate
• changes in respiratory rate
• white blood cell count

Once the early signs of sepsis are identified, the hospital is able to administer treatment quickly-- and greatly improve the patients survival rate.  At Banner Medical Center, the hospital credits the new program with the early detection of sepsis in 60 patients within the first two-month period that traditional detection techniques were unable to spot.  Read more about this important development in sepsis detection here.

My hope is that the sepsis detection instruments used at this hospital become common practice-- not just amongst hospital patients-- but nursing home patients as well who frequently receive delayed medical treatment because nursing home staff do not have the tools to make a diagnosis of sepsis.

Related:

Is sepsis related to bed sores? BedsoreFAQ.com

Despite Their Avoidability, Bed Sores Continue To Plague Nursing Home & Hospital Patients In All Demographics

Lawsuit Alleges: One Week In The Nursing Home Results In Significant Deterioration Of Pressure Sores & Sepsis

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A Philadelphia jury awarded $5 million in punitive damages to the widow of a man who died from bed sores he developed during a hospitalization and then worsened during a subsequent nursing home admission.  The case, believed to be the first of its kind in terms of awarding punitive damages against a nursing home in Philadelphia courts, was allocated: $1.5 million against Jeanes Hospital and $3.5 million against Hillcrest Convalescent Home. 

According to widow's lawyer, Steven R. Maher, Jeans Hospital failed to diagnose the man's urinary tract infection that contributed to the development of bed sores (also referred to as: pressure sores, pressure ulcers or decubitus ulcers) and then the man was transferred to Hillcrest Nursing Home where the bed sores worsened.  Despite his wife's best efforts to care for her husband at home, the man succumbed to the bed sores approximately two years after he developed them.

This punitive damage award is in addition to a $1 million compensatory damage award a jury had previously awarded in the case.   Incidentally, Jeanes Hospital is part of the Temple University Health System and Hillcrest is owned by Genesis HealthCare Corp., a large nursing home operator in the Northeast.

While punitive damages are rare due to the high threshold an injured party must prove, in this case 'outrageous and reckless conduct', it doesn't surprise me that these type of damages were awarded in a bed sore case.  Obviously, the plaintiff's lawyers did a great job presenting their case, but when jurors hear and see how devastating a bed sore can be, it most definitely evokes feelings of rage-- when they see how a medical facilities neglect resulted in such devastating injuries.

Related:

Unusual damages set in Phila, bedsores case, Philly.com, March 17, 2010

Over 500,000 Adults Suffer From Bed Sores In Hospitals

New York Jury Punishes Nursing Home Where Man Develops More Than 20 Bed Sores

If a lawsuit or claim is filed against a facility where a person developed bed sores, what type of damages is the person entitled to?

Bed Sore Pictures, Bed Sore FAQ

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The family of a man with a spina bifida has filed a lawsuit against Tower Hill Healthcare Center, alleging the facilities neglect resulted in the man's physical injury and deterioration since he was admitted to the facility.  

According to the lawsuit, the man was admitted to Sherman Hospital on July 5, 2008 for an elevated body temperature.  However, when staff at the hospital examined the man they noticed other problems such as: poor oral hygiene, bed sores (also referred to as: pressure sores, pressure ulcers or decubitus ulcers) covered with feces and an exploded colostomy bag. 

Consequently, the hospital staff reported the suspected mistreatment to the Illinois Department of Health to investigate further.

The man died on July 31, 2008 due to a staph infection and pneumonia.  This nursing home negligence lawsuit is pending in Kane County, Illinois.  Read more about this lawsuit against Tower Hill Healthcare Center here.

About Tower Hill Healthcare Center

Tower Hill Heathcare Center is located at 759 Kane Street in South Elgin, Illinois.  Despite the facilities relatively impressive 4-star (out of 5 stars) rating, the facility has been cited numerous times for safety violations related to patient injury.  The majority owner is of Tower Hill is Jack Rajchenbach.  Mr. Rajchenbach knows his was around Illinois nursing homes, having ownership interest in the following facilities:

• BRIDGEVIEW HEALTH CARE CENTER 
• THE CARLTON AT THE LAKE
• CLARK MANOR CNV CENTER
• SPRINGFIELD TERRACE 
• TOWER HILL HEALTHCARE CENTER 
• GLENVIEW TERRACE NURSING CENTER
• THE IMPERIAL GROVE PAVILION
• THE ARC OF JACKSONVILLE, LTD.
• GROVE LINCOLN PARK LVG & REHAB
• PETERSON PARK HEALTH CARE CTR
• EMBASSY HEALTH CARE CENTER
• GROVE NORTH LIVING & REHAB CTR
• WHITEHALL NORTH
• HARMONY NURSING & REHAB CENTER

Related:

Why is a colostomy needed for patients with severe bed sores?

What are the signs of infection for people who have bed sores?

Is sepsis related to bed sores?

What are nursing homes required to do to prevent bed sores?

Why are physically disabled patients at risk for developing bed sores?

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In times of need, locating necessary information regarding the legal rights and resources for nursing home patients can be difficult and imposing.  In this respect, we are proud to introduce a new resource for patients, families and practitioners looking for a concise compilation of information regarding nursing home laws.  Nursing Home Injury Laws, provides every states':

• Nursing Home Laws
• Medical Malpractice Laws
• State Resources
• Applicable State Code

Additionally, we will be posting regular updates regarding important developments relevant to nursing home care within each state.  Here is a link to Nursing Home Injury Laws.

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The son of a deceased nursing home patient blames 'under-staffing' as the primary reason why his mother fell and subsequently developed pressure ulcers.  Gary Brown filed a lawsuit against a county operated nursing home in Nebraska on behalf of his deceased mother's estate.

In addition to under-staffing, the lawsuit alleges the facility allowed his mother to develop pressure ulcers (also referred to as pressure sores, decubitus ulcers or bed sores) during her recovery from a fall at the facility. Despite the fact that the pressure ulcers progressed and became infected, the facility also allegedly failed to notify the woman's personal physician.  Lastly, it is claimed that the pressure sores contributed to the patient's death.

Read more about this lawsuit due to development of pressure ulcers here.

Nursing Homes Obligation To Prevent Pressure Ulcers

Nursing homes must develop a customized program to prevent and monitor each resident's risk for developing pressure ulcers.  Unfortunately, at facilities that are inadequately staffed, many of the preventative measures set forth in a care plan are not complied with.

Pressure ulcers may develop when a patient is left in one position for a long period of time. Consequently, many nursing home patients need to be 'turned' on a regular basis.  Many facilities have charts to help staff keep track of the re-positioning schedule for each resident.

To minimize development of pressure ulcers, nursing home residents should be:

• Cleaned regularly with mild soap and lukewarm water
• Moisturized daily
• Kept dry and clean-- especially kept free from urine and feces
• Rotated on schedule to prevent the build up of pressure from one area of the body
• Encouraged to get proper nutrition and hydration
• Kept the bed elevation as low as possible- this reduces pressure on the sacrum and buttocks

Related Nursing Homes Abuse Blog Entries

Government Report Confirms Pressure Ulcers Harm All Nursing Home Residents; Regardless Of Race, Sex or Age

Nursing Home Visits. An Opportunity To Conduct Your Own Inspection.

In For Rehab. Out With Bedsores.

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Most of the time a family contacts my office, it is due to an incident involving abuse or ongoing neglect. Although perhaps less obvious, after we investigate many of the cases, the underlying problem may be a complex medical condition that may ultimately prove important in successfully prosecuting the matter.

Here are some of the medical conditions we have discussed over the past year:

Clostridium Difficile / C. Diff

Clostridium difficile (also called C. difficile or C. diff) associated disease (“CDAD”) is a bacterial infection that can cause diarrhea and serious intestinal conditions (such as colitis - inflammation of the colon). CDAD is responsible for about three million cases of diarrhea and colitis annually in the United States.

Stevens Johnson Syndrome

Stevens-Johnson Syndrome (“SJS”) is a systemic disorder that affects the skin and mucous membranes, usually caused by a severe drug reaction. SJS often begins with flu-like symptoms (fever, sore throat, cough, burning eyes), then progresses to red or purple rashes and blisters (photos), especially around the mouth, nose, eyes. These symptoms eventually lead to skin sloughing (the shedding of the top layer of skin) because of cell death. Some patients with extreme cases of SJS appear as though they were severely burned due to the extensive skin loss.

Legionnaires Disease

Legionnaires disease is an infectious disease caused by the Legionella bacteria. There are two types of Legionnaires disease: Legion fever (where people generally develop pneumonia) and Pontiac Fever (symptoms similar to the flu).

Legionnaires disease got its name when a group from the American Legion conference all developed pneumonia. When scientists analyzed the group, they noticed that they all had the same bacterium called Legionella.

Subdural Hematoma

A subdural hematoma is a type of intracranial bleeding (hemorrhage), caused by head injury. Subdural hematomas occur when blood vessels burst in the space between the brain and the outermost membrane that covers the brain (dura mater). The collection of blood forms a hematoma, which puts pressure on the brain tissue.

There are three types of subdural hematomas: acute, sub-acute, and chronic. Acute subdural hematomas are the most dangerous and are usually caused by a severe head injury. With sub-acute hematomas, the signs and symptoms take longer to appear (days or weeks). Chronic hematomas can be caused by less severe head injuries, and symptoms can take weeks to appear because of slower bleeding.

Hypotension

Hypotension (low blood pressure) is a problem for many nursing home residents, causing dizziness and fainting. Blood pressure readings measure the pressure in arteries - systolic pressure (the top number in a reading) measures the pressure the heart generates when pumping blood out to the rest of the body and diastolic pressure (the bottom number in a reading) measures the amount of pressure between heartbeats. A systolic blood pressure of 90 millimeters of mercury or less or a diastolic blood pressure of 60 millimeters of mercury or less is considered low.

Sepsis

'Sepsis' is a bacterial infection in the bloodstream or body tissues, frequently found in patients with severe bed sores. In order to make a diagnosis of sepsis, at least two of the following must occur: a heart rate above 90 beats per minute, hyperventilation (more than 20 breaths per minute) and white blood cell count below below 4000 cells/mm.

Frequently, people use the term sepsis to describe 'severe sepsis' and 'septic shock.' Severe sepsis is used to describe people who have organ dysfunction following a diagnosis of sepsis. People diagnosed with septic shock have sepsis with hypo-tension (abnormally low blood pressure).

Amyloidosis

Elderly nursing home residents, especially those suffering from other diseases such as bed sores, have a higher risk of developing amyloidosis, a disease which can damage various tissues and organs. This can cause dangerous complications in residents who are already weak from advanced age or underlying disease.

Amyloidosis is a group of diseases caused by abnormal deposits of amyloid protein (usually produced by cells in bone marrow) in the body’s tissues and organs. The disease frequently affects the heart, kidneys, liver, spleen, nervous system, and gastrointestinal tract. The amyloid protein can deposit in a localized area (localized amyloidosis) or affect tissues throughout the body (systemic amyloidosis). Amyloidosis is diagnosed for testing for the amyloid protein in a biopsy of involved tissue.

Impacted Bowel

An impacted bowel is the condition where feces are trapped in the lower part of the large intestine, causing a waste obstruction. The stool collects in the bowel and becomes hardened. This hard stool can irritate the rectum, resulting in the production of mucus and fluid which can leak, causing fecal incontinence.

One of the most common symptoms is lack of appetite, caused by pressure on the abdomen. Hemorrhoids (a mass of dilated veins in swollen tissue around the anus) are a common sign of impacted bowels because it is more difficult to rid your body of fecal matter. Other symptoms include: a constant feeling of fullness; diarrhea; hardened feces; cramping and pain; vomiting; constipation; bad breathe; and bloating. If left untreated, the waste obstruction can cause a rectal infection that can lead to sepsis or death.

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Autonomic dysreflexia (or hyperreflexia) is a dangerous condition that can occur with bed sore patients or patients with spinal cord injuries above the middle of the chest (usually above T-5).  Autonomic dysreflexia occurs when an irritation or pain below the level of the spinal cord injury sends a signal that fails to reach the brain.  

Over time, the bodies a delayed pain response results in changes to the sympathetic portion of the autonomic Nervous System (helps people adapt to changes in the environment and is associated with the “flight-or-fight” response), resulting in muscle spasms and a narrowing of the blood vessels.  This in turn can cause blood pressure to rise and heart rate to drop, which can lead to stroke, seizure, or even death. 

Signs autonomic dysreflexia may include:

• Pounding headache
• Goose bumps
• Red blotches on the skin, above the level of the spinal cord injury
• Sweating, above the level of injury
• Cold, clammy skin, below the injury
• Nasal congestion
• Slow pulse (< 60 beats/minute)
• Restlessness
• Hypertension (blood pressure greater than 200/100)
• Nausea

Autonomic dysreflexia can be prevented.  Specific precautions include:

• Frequent pressure relief in bed / chair (turning the patient to change positions)
• Avoidance of sunburn and scalding from hot water
• Maintain a regular bowel program
• Proper nutrition and fluid intake
• Compliance with medications
• Proper maintenance of indwelling catheter (keep tube free of kinks, keep drainage bags empty, check catheter daily for deposits)
• Perform routine skin assessments

Treatment of autonomic dysreflexia can be as easy as changing positions or removing the cause of irritation.  However, treatment must be initiated quickly in order to prevent further complications.  Many stimuli can cause autonomic dysreflexia including anything that would have been painful, uncomfortable, or physically irritating before the injury.  

The most common causes are:

• Overfill bladder – this can be due to a blockage in urinary drainage device, bladder infection, inadequate bladder emptying, bladder spasms, or bladder stones
• Bowel full of stool or gas – due to constipation, hemorrhoids or anal fissures, or infection and irritation
• Skin irritations – due to wounds below the injury, pressure sores, ingrown toenails, burns, or tight/restrictive clothing
• Broken bones

If the trigger cannot be identified and removed or if problems persist, medications can be used to treat the autonomic dysreflexia. 

People suffering from spinal cord injuries are particularly susceptible to pressure sores because of sitting or lying in the same position for an extended period of time.  In addition, spinal cord injuries can reduce or eliminate sensations, making it more difficult for the person to know when a pressure sore is developing.  These pressure sores can cause a dangerous condition known as autonomic dysreflexia in patients with spinal cord injuries.  

Autonomic dysreflexia is a potentially life threatening condition resulting from over activity in the Autonomic Nervous System, which can cause high blood pressure leading to seizures, stroke, and even death.  

Therefore, it is important that nursing home staff pay special attention to residents suffering from spinal cord injuries.  This includes frequently turning the resident to relieve pressure, regulating bladder and bowel output, properly maintaining catheters, and regularly checking for skin irritations.  Prevention of pressure sores is key to maintaining the physical health of residents with spinal cord injuries. 

Related:

Are bed sore patients at risk for amyloidosis?

Can bed sores cause osteomyelitis?

Is necrotizing fasciitis related to bed sores?

If bed sores are not timely treated, can gangrene develop?

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It never fails to amaze me.  Frequently, when I tell people about some of the cases I work on involving bed sores, I only to get a 'so what?' reaction from them.  Are the people who surround me heartless?  Maybe some of them (just joking, honey)?  Nonetheless, the reality is that most people have no idea what a bed sore truly is or the catastrophic consequences that my arise after a person develops them.

When people actually see the gruesome photos of rotting flesh on a person's backside hear about the ongoing medical procedures that are necessary to heal the wound, they begin to understand the real impact of this medical condition.

Along these lines, an obviously compassionate jury in New York awarded the family of a man who succumbed to infection following the development of bed sores almost $19 million.  The New York Post reported that the Brooklyn jury's award was comprised of $3.75 for the man's pain and suffering and a hefty $15 million in punitive damages.

According to the man's daughter's Margaret Whitehurst, the man rapidly declined during his nine month admission to Brooklyn Queens Nursing Home.  "He walked in on two legs and a cane.  He was 237 pounds.  When we got him back, he was 148 pounds and had holes all over his body."

In addition to hearing testimony regarding severe bed sores (also called: decubitus ulcers, pressure ulcers or pressure sores), the jury also heard from an expert witness who testified about how the nursing home altered the man's medical records to make it appear as though he entered the facility with bed sores.

Not having any firsthand knowledge of whether the nursing home made any offer to settle the case prior to trial, I can only assume the offer was insignificant.  I'll bet this facility is now re-thinking its decision to avoid responsibility for the death of this patient.

Read more about this nursing home lawsuit here.

Related:

Lawsuit Claims That Nursing Home's Negligence Resulted In Patient's Decubitus Ulcers

Lawsuit Alleges: One Week In The Nursing Home Results In Significant Deterioration Of Pressure Sores & Sepsis

Nursing Home Negligence Lawsuit Claims New York Facility Allowed Advanced Bed Sore To Develop In Rehab Patient

Big Verdicts Against Nursing Homes

What should I do if my family member develops bed sores during an admission to a nursing home?

Resource:

Nursing Home Injury Laws

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Although the news regarding the horrific physical and emotional impact of bed sores (also called decubitus ulcers, pressures sores or pressure ulcers) surely is on all respectable medical professionals radar screens, bed sores in nursing homes and hospitals continue to plague individuals in all demographics.  In order to improve patient care, bed sore prevention must be a priority at all nursing homes and hospitals.

Should a bed sore develop, staff must be diligent in identifying the wound as quickly as possible an implement the use of medical equipment such as pressure relieving mattresses  and other pressure relief devices such as heel protectors to prevent the wounds from advancing.

When bed sore are not timely treated, the wounds may progress and become an advanced stage bed sore. A stage 3 or 4 bed sore typically requires more aggressive interventional medical treatment may be required such as surgical debridement, flap reconstruction or a diverting colostomy may be necessary.

By the time significant medical treatment his utilized, many patients are already suffering from complications such as: osteomyelitis, amyloidosis, gangrene or sepsis. 

In addition to the pain that accompanies bed sores, the medical complications may claim the life of the person.  In my practice, we commonly represent families in wrongful death lawsuits for people who have developed bed sore during an admission to a hospital or nursing home.

Many of these commonly encountered situations are discussed at BedSoreFAQ.com, where we receive thousands of visits every month from concerned family members and care givers. If you have a question, not discussed, feel free to contact me for a no-obligation consultation. (888) 424-5757. Toll-free. Anywhere

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A colleague forwarded me this video with Dr. Dale Bratzler of the Oklahoma Foundation for Medical Quality as he discusses the prevalence of pressure ulcers amongst patients in nursing homes and hospitals in the state.  Unfortunately, Oklahoma is one of the top five worst states in terms of frequency of development of pressure ulcers.

Dr. Bratzler suggests that the best method of prevention is to educate 'front line workers'-- those who typically provide the most hands-on patient care as to what can be done to from a prevention standpoint and how identify the wounds in their early stages before they become particularly problematic.

I couldn't agree more.  In my experience by the time a pressure ulcer (similarly called: bed sore, decubitus ulcer or pressure sore) has developed, it is really a display of a complete breakdown in patient care at the entire facility.  In the days and weeks a stage 3 or 4 pressure ulcer develops, it literally means that shaft-after-shift of nurses or aides failed to do their job.

Related:

Why do nursing homes describe pressure sores according to 'stages'?

A Graphic Example Of Nursing Home Negligence: Amputation Of A Leg Due To Untreated Bed Sores

Updates From Bed Sore FAQ. Top-Ten Most Visited Entries

Reducing Decubitus Ulcers In Hospitals. How One Facility Managed To Reduce Hospital-Acquired Wounds By 63%

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After a one week stay at Caseyville Nursing and Rehabilitation, Theresa Mary Steiner's pressure sores significantly deteriorated to the point that she had become 'septic' according to a recently filed lawsuit.  The lawsuit claims that on December 12, 2008 Ms. Steiner was admitted to the facility with stage II pressure sores on her buttocks and early stage pressure sores on her heels.  Five days later, when Ms. Steiner was discharged, the pressure sores (also known as pressure ulcer, decubitus ulcer or bed sore) had advanced to stage IV and Ms. Steiner had become known as septic.  As a result of the sepsis, Ms. Steiner died.

The lawsuit further alleges that Caseyville Nursing and Rehabilitation was negligent in the following ways:

• Failing to screen Ms. Steiner on admission to the facility
• Failed to have adequate staff to treat Ms. Steiner's wounds
• Never developed a care plan for Ms. Steiner
• Never notifying Ms. Steiner's physician as to her condition

My take:

With the obvious disclaimer (I don't know anything about the case other from what is in the newspaper), it would appear as though the Ms. Steiner's family may have a difficult time winning their case. 

As the plaintiff in this matter, Ms. Steiner's family has the burden to prove their case.   Given the fact that Ms. Steiner enter the nursing homes with clearly form pressure sores and the wounds worsened in such a brief period of time, perhaps the damages was done by the time she had entered the facility?

Sepsis and Pressure Sores

With open wounds from pressure sores, bacteria can easily enter the bloodstream and cause and infection in the body.  When the infection progresses, it may cause sepsis. In order to make a diagnosis of sepsis, at least two of the following must occur: a heart rate above 90 beats per minute, hyperventilation (more than 20 breaths per minute) and white blood cell count below below 4000 cells/mm.

Symptoms of sepsis include:

• Fever
• Low body temperature (hypothermia)
• Loss of ability to appreciate surroundings
• Cool hands and feet
• Anxiety
• Shaking
• Organ dysfunction

In order to provide patients with the best chance of recovery, facilities should identify and treat patients as quickly as feasible. If not treated properly, many patients with sepsis die shortly after the condition develops.

Resources:

Is sepsis related to bed sores? Bed Sore FAQ

Nursing home blamed for resident's sepsis St. Clair Record, December 7, 2009

Sepsis Nursing Homes Abuse Blog August 7, 2008

Nursing Home Injury Laws

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I recently received an email from the National Decubitus Foundation mentioning how only a handful of states currently require hospitals to report the incidence of 'never events' to authorities that occur at their facilities.  Consequently, the patient / consumer is left in the dark when it comes to 'good' vs. 'bad' hospitals.

'Never events' are preventable medical errors that the government (Medicare) has deemed so unnecessary that hospitals can not bill Medicare for medical treatment related to a patients subsequent care.

Here is an excerpt of the email:

Hospitals Resist Reporting
Several States Trying to Enforce Disclosure Laws

Only a handful of states require reporting of all "never events", including pressure ulcers, but those that do are meeting extreme resistance from the hospital lobby. This issue of The Ugly Secret highlights several stories that have appeared in the past few weeks showing how states are attempting to overcome this defiance.

A recent story in the NY Daily News (September 16, 2009) was headlined:

"Hospital lobbyists hope to maim patient care reporting bill". The story continues, "High-priced hospital lobbyists are furiously trying to kill a bill that would give New Yorkers a report card on nurse staffing and other key patient-care issues.
The bill also requires reporting of other indicators such as bedsores, patient falls and medical errors relating to nurse staffing.

"The public has a right to know when they go to a hospital or nursing home what they can expect," said Tina Gerardi, CEO of the New York State Nurses Association.

The Healthcare Association of New York and the Greater New York Hospital Association are fighting the legislation.

Bolstering its large in-house team, HANYS has paid the state's highest-ticket lobbying firm, Wilson Elser Mostkowitz Edelman and Dicker, more than $102,000 this year to fight for them on this and other issues.

The association also has contributed at least $20,000 to Paterson's campaign, filings show.

The Greater New York Hospital Association gave $115,000 to Patricia Lynch Associates and Bolton St. Johns to lobby for them.

The effort follows a Daily News series that found city-run hospitals have been repeatedly cited for not reporting medical mishaps, including fatal errors.

'This is simply not the year to impose more new mandates given the multiple and significant state budget cuts over the past year and the fiscal challenges on the horizon,' HANYS said in an opposition memorandum. "

The current list of 'never events' includes the following (unfortunately) commonly encountered situations:

Surgical Events

• Surgery performed on the wrong body part
• Surgery performed on the wrong patient
• Wrong surgical procedure on a patient
• Retention of a foreign object in a patient after surgery or other procedure
• Intraoperative or immediately post-operative death in a normal healthy patient
• Infection of surgical site

Medical Device Errors

• Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
• Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
• Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
• Catheter- associated urinary tract infection

Hospital Staff Errors

• Infant discharged to the wrong person
• Patient death or serious disability associated with patient disappearance for more than four hours
• Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
• Patient death or serious disability associated with a medication error
• Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO- incompatible blood or blood products (transfusion of the wrong blood type)
• Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy while being cared for in a healthcare facility
• Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
• Death or serious disability (kernicterus) associated with failure to identify and treat jaundice in newborns
• Stage 3 or 4 pressure ulcers (also referred to as: pressure sores, pressure ulcers or decubitus ulcers) acquired after admission to a healthcare facility
• Patient death or serious disability due to spinal manipulative therapy

Dangerous Conditions Within The Hospital

• Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
• Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
• Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
• Patient death associated with a fall while being cared for in a healthcare facility
• Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

Criminal Acts Within A Hospital

• Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
• Abduction of a patient of any age
• Sexual assault on a patient within or on the grounds of a healthcare facility
• Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

Now that the government has literally spelled out the preventable medical events that hospitals should easily be able to avoid, don't patients deserve to know which medical facilities are doing a good job and which are not?  What else is the point of keeping tack of this data?

If you believe an injury to death was due to a medical facilities commitment of a 'never event' we may be able to help you.  We have successfully prosecuted may of the above situations on behalf of our clients.  For a free, confidential consultation give my office a call toll-free (888) 424-5757. Put our experience to work for you!

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"What do nursing homes describe pressure sores according to stages?"

-Edith Phoenix, AZ

Nursing homes and hospitals use a four stage scale to describe, monitor and treat pressure sores (also called bed sores, pressure ulcers or decubitus ulcers).  By categorizing pressure sores, according to standardized characteristics, a sense of uniformity can be established amongst all medical facilities that treat people with pressure sores.

Bed sores are categorized based on their severity (stage 1, stage 2, stage 3 or stage 4). The National Pressure Ulcer Advisory Panel, a professional organization dedicated to the prevention and treatment of bed sores, has set forth specific characteristics to help medical professionals objectively categorize a wound.

Stage I- Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.

Stage II- At this point, some skin loss has already occurred — either in the epidermis, the outermost layer of skin, in the dermis, the skin’s deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.

Stage III- By the time a pressure ulcer reaches this stage, it has extended through all the skin layers down to the muscle, damaging or destroying the affected tissue and creating a deep, crater-like wound.

Stage IV- In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections.

Occasionally, a bed sore may be categorized as ‘unstageable‘. Unstageable bed sores are usually referred to as an extremely advanced wound where there is involvement of skin, muscle and bone.

Bed-bound patients commonly develop pressure sores in the following areas: back or sides of your head, rims of ears, shoulders, hip bones, lower back or tailbone, knees, heels, ankles and toes.

 Resource:

Bed Sore FAQ

National Pressure Ulcer Advisory Panel

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One of the nursing home negligence cases my office is currently investigating involves the death of a man related to complications related to amyloidosis.  Turns out, the man was suffering from an advanced bed sore on his coccyx (also called pressure ulcers, pressure sores or decubitus ulcers) that had progressed so far that the bone in the area had become infected (osteomyelitis).

Elderly nursing home residents, especially those suffering from other diseases such as bed sores, have a higher risk of developing amyloidosis, a disease which can damage various tissues and organs.  This can cause dangerous complications in residents who are already weak from advanced age or underlying disease.

Amyloidosis is a group of diseases caused by abnormal deposits of amyloid protein (usually produced by cells in bone marrow) in the body’s tissues and organs.  The disease frequently affects the heart, kidneys, liver, spleen, nervous system, and gastrointestinal tract.  The amyloid protein can deposit in a localized area (localized amyloidosis) or affect tissues throughout the body (systemic amyloidosis).  Amyloidosis is diagnosed for testing for the amyloid protein in a biopsy of involved tissue. 

Systemic amyloidosis is classified into three major types:

• Primary (AL) amyloidosis
• Secondary (AA) amyloidosis
• Hereditary or Familial (ATTR) amyloidosis

Primary amyloidosis, the most common form of amyloidosis, occurs when a plasma cell in the bone marrow spontaneously overproduces a particular protein portion of an antibody.  AL can affect many areas (heart, kidneys, liver, spleen, nerves, intestines, skin, tongue, blood vessels) and can occur with bone marrow cancer (bone marrow cancer), but is a disease entity of its own.

Secondary amyloidosis occurs as a result of another illness (multiple myeloma, chronic infections including tuberculosis and osteomyelitis, or chronic inflammatory diseases including rheumatoid arthritis and ankylosing spondylitis).  It usually affects the kidneys, spleen, liver, and lymph nodes.  Treatment for AA is usually treating the underlying illness.

Familial amyloidosis is a rare form of inherited amyloidosis that is an inherited autosomal dominant disease (meaning that the offspring of a person with the condition has a 50% chance of inheriting it).  ATTR usually affects the liver, nerves, heart, and kidneys. 

The signs and symptoms of amyloidosis depend on the tissues or organs affected.  The symptoms result from abnormal functioning of the organs and tissues involved.  They may include:

• Swelling of ankles and legs
• Numbness or tingling in hands or feet
• Severe fatigue
• Weakness
• Significant weight loss
• Loss of appetite
• Shortness of breath
• Irregular heartbeat
• Diarrhea or constipation
• Protein in urine
• Feeling full quickly
• Enlarged tongue
• Difficulty swallowing
• Swelling
• Skin changes (thickening or easy bruising)
• Purplish patches around the eyes

 Risk factors for amyloidosis including:

• Age – older than 65
• Other diseases – having chronic infections or inflammatory disease or osteomyelitis
• Family history – history of amyloidosis
• Kidney dialysis – large, abnormal proteins can build up in the blood

The severity of the disease depends on which organs and tissues are affected.  The disease can result in dangerous complications including kidney damage, heart damage, and nervous system damage.  Kidney damage can result when amyloidosis affects the kidneys.  Kidney problems frequently translate to damage with the bodied blood filtering system, allowing protein to leak from the blood into the urine.  This may result in kidney failure. 

Heart damage can also occur when amyloidosis affects the heart.  This reduces the heart’s ability to fill with blood between heartbeats, meaning less blood is pumped with each beat.  Nervous system damage can also occur when amyloid protein deposits affect the nerves.  This can result in numbness, tingling, or difficulty controlling blood pressure. 

There is no cure for amyloidosis, but treatment may help manage the signs and symptoms of the disease, limit further production of amyloid protein, and treat any underlying disease.  Several treatments of primary amyloidosis are being studied including medicine and peripheral blood stem cell transplantation. 

Nursing home residents suffering from painful pressure sores are at an increased risk for amyloidosis.  Should a pressure sore patient develop amyloidosis, they run the risk of organ tissue damage and increased risk of amyloid protein deposits.  Also, paraplegic patients suffering from sepsis as a result of pressure sores also face complications stemming from amyloidosis. 

Sources:

Mayo Clinic: Amyloidosis

Boston University: Amyloid Treatment and Research Program

Amyloidosis Foundation

Pressure sores: aetiology, treatment and prevention (Colin Torrance)

Related:

Bed Sore FAQ

Bedsores: Are You At Risk?

In For Rehab. Out With Bedsores.

"The Nursing Home Says My Dad's Bedsores Were Unpreventable..."

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A home-care nurse has been charged with criminal mistreatment after she failed to seek medical attention for an elderly woman with severe bed sores that ultimately claimed her life.  Prosecutors filed the charges against, Virginia Munger after an investigation revealed that although Munger was aware of advanced bed sores (also referred to as: decubitus ulcers, pressure ulcers or pressure sores) for six months, she took no medical intervention.  Munger was employed as a CNA by Homewell Senior Care, a home-care nursing company.

Read more about this case of senior neglect here.

Home Care Services

Many seniors are turning to home-care services as a way of living independently for longer.  Many of these companies offer senior a variety of medical and non-medical services and provide staffing on as 'as needed' basis.  Unlike nursing homes, home-care services are loosely regulated by federal and state officials. 

Officials at home care service companies should conduct an assessment to determine what the patient's needs are and determine if the company can indeed provide those services.  Once the needs are assessed and services are provided, the company should provide supervision of its employees to make sure those services are properly provided and the patient's needs are continually met.

In the case above, the elderly woman's family may have a cause of action against the home service company-- not necessarily for the criminal conduct of its CNA, but for failing to provide adequate supervision.  Additionally, if the company was made aware of the woman's bed sores-- yet failed to take any action they may similarly be liable for her treatment and death.

Related Nursing Homes Abuse Blog Entries

Home Care Nurse Gets Probation For Ignoring Bedsores On Child

Home Care Nurse Has License Suspended In Connection To Death Of Disabled Boy

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Deciding whether to have an autopsy performed on a loved one is indeed a very personal decision for a family to make following a death.  An autopsy can help a family get answers to not only the cause of death, and in the case of potential nursing home negligence, what-- if any, errors may have been made by a medical facility that may have caused the death.

After reading this news article about how a disabled nursing home patient may have 'choked to death' on his lunch I was reminded by how valuable autopsies can be where a death may occur in a nursing home or hospital setting that is insulated from the public.

What is an autopsy?

An autopsy is a detailed medical examination of the person's body and organs following death to establish the specific cause.  Autopsies are performed by a physician, a pathologist, who is trained to evaluate results from physical examinations and laboratory results from tissue and blood samples to determine the cause of death.

Once the examination and laboratory results have been evaluated, an autopsy report is rendered. The report notes the physical findings and states a cause(s) of death.  Because the report is rendered from an impartial author, it can be particularly useful in a litigation setting.  Similarly, just a the report may be useful in case against a nursing home or hospital, results may also absolve the facility of responsibility if the results do not substantiate poor care. 

In order to secure the most accurate results, most pathologists suggest performing an autopsy 24 to 48-hours after the death of a person.  Depending on where the death occurred  and the circumstances surrounding it, the autopsy may be performed by the state medical examiner or by a physician at a private hospital.

Is an autopsy called for in cases where nursing home neglect may have occurred?

In my opinion, particularly in cases involving the elderly, autopsies can be extremely helpful in rebutting arguments made by facilities who may argue that a death was the result of 'old age' or due to a 'variety complicated medical factors'.

Autopsies can be particularly helpful in the following wrongful death matters:

• Bed sores (also referred to as: decubitus ulcers, pressure sores or pressure ulcers)
• Malnutrition
• Dehydration
• Medication errors / overdoses
• Medical errors
• Falls with accompanying subdural hematoma

If you wish to have an autopsy performed on a loved one, you should contact your coroner or local hospital to get information about facilities that can perform one at your request.

Related Nursing Homes Abuse Blog Entries

Autopsy Confirms Man Was Murdered In Chicago Nursing Home

Medical Examiner Rules Tennessee Nursing Home Death A Homicide

Grandson Alleges Poor Nursing Care Results In Bed Sores "You Could Stick Your Fist" In

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In addition to monitoring food and liquid intake of nursing home patients, staff need to pay attention to the elimination of the wastes.   When urine and feces are not produced on a regular basis, nursing home staff must bring these problems to the attention of physicians.

One of the more obvious cases of nursing home neglect my office is working on involves a patient who went at least 10 days without a bowel movement.  Shift after shift of nursing home staff tended to our client-- yet no one cared enough to look at his medical chart to see when the last bowel movement occurred.  It was not until the man was taken to a local hospital, was it determined that the man's bowel had become impacted with feces.  Within 24-hours of his admission to the hospital, the man died from complications related to sepsis.

What is an impacted bowel?

An impacted bowel is the condition where feces are trapped in the lower part of the large intestine, causing a waste obstruction. The stool collects in the bowel and becomes hardened. This hard stool can irritate the rectum, resulting in the production of mucus and fluid which can leak, causing fecal incontinence. 

One of the most common symptoms is lack of appetite, caused by pressure on the abdomen. Hemorrhoids (a mass of dilated veins in swollen tissue around the anus) are a common sign of impacted bowels because it is more difficult to rid your body of fecal matter. Other symptoms include: a constant feeling of fullness; diarrhea; hardened feces; cramping and pain; vomiting; constipation; bad breathe; and bloating. If left untreated, the waste obstruction can cause a rectal infection that can lead to sepsis or death. 

The most common cause of impacted bowel symptoms is Crohn’s disease.  In a nursing home setting, causes of impacted bowel include: not drinking enough water; not eating a diet with adequate fiber; lack of activity; certain prescription medications and generally unhealthy diet with high fat and processed foods.

When timely identified, impacted bowels can be treated with a higher fiber diet, increased hydration, exercise, laxatives, enemas, suppositories, or manually removing the hardened feces.

Unfortunately, many nursing home patients are highly susceptible to impacted bowels due to a combination of inattentive staff and an unhealthy lifestyle.  In order to minimize the chances of impacted bowels among patients, nursing homes should:  

• Provide the residents with proper nutrition (sufficient fiber, water, and healthy foods), the residents can suffer from painful constipation. 
• Provide as much physical activity as feasible for patients.
• Monitor each patients bowel movements (time, quantity, consistency)  
• Pay special attention to patients complaining of stomach pain or cramping

Resources:

Article Click - Fecal Impaction vs. Constipation

The association of fecal impaction and urinary retention in elderly nursing home patients

Annals of Internal Medicine – Incontinence in the Nursing Home

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In order to heal a pressure ulcer, staff at nursing homes, hospitals or wound clinics must pay extra attention to dressings on the wound. Too often, the problems associated with pressure ulcers are compounded when staff fail to follow physician orders with respect to the frequently of dressing changes or the dressings changes are not done properly.

When dressing changes are not properly done, the wound will take longer to heal and the likelihood of infection increases.  This video demonstrates proper dressing changing technique.

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One of the trends in nursing home litigation has been the inclusion of mandatory arbitration agreements in admission paperwork.  By signing an arbitration agreement (usually unknowingly), nursing home patients may surrender their opportunity to recover money for an injury via a traditional jury trial.  Alternatively, injured parties must present their grievances before an individual or group of arbitrators.    

The arbitration agreements set forth the terms of the arbitration and how many arbitrators will hear the matter.  Generally, in the case of a single arbitrator, the individual is selected by the nursing home.  In the case of an arbitration panel (usually three people) both the nursing home and the injured party may choose an arbitrator, with a third arbitrator selected by the appointed arbitrators.

Because the ability to award money for an injury or wrongful death is taken out of the hands of jurors and into the power of individuals who may be influenced by industry power-- mandatory arbitrations are usually vigorously fought by injured parties. 

Until recently, it was universally believed that an injured person stood little chance of receiving a fair recovery in an arbitration setting because many of the arbitrators had allegiance to large nursing home operators and other appointed arbitrators may be unfamiliar with issues that frequently arise in nursing home injury matters.

That was then, this is now.

Recently, a three-person arbitration panel recently awarded over $2.7 million in damages to the family of Voncil Sherrod who died in March, 2005 from complications related to gangrene and advanced pressure sores that developed during her admission to High Point Health Care and Rehabilitation Center in Tennessee.

In addition to High Point, damages were also sought from Mariner Health Care (the parent company), Mariner Health Care Management (the management company) and National Heritage Realty Company (the licensee).  Ms. Sherrod's estate claimed that all entities were guilty of: negligence, violation of the Tennessee Adult Protection Act (TAPA) and medical malpractice.

In making this substantial award, the arbitration panel obviously sent a message to the various nursing entities that they can no longer assume that taking a nursing home negligence matter away from a jury will protect them from liability.  Also, notable was the large award for punitive damages against the facilities especially in light of the more modest awards for other claims.

The arbitration award is comprised of the following:

• $250,000 for TAPA violations
• $400,000 in attorneys fees for intentional, malicious or fraudulent misconduct resulting in TAPA violations
• $626,396.32 for medical malpractice 
• $1,500,000 punitive damages

Related Nursing Homes Abuse Blog Entries:

A Legal Victory For Nursing Home Residents. State Laws Can Supersede Federal Arbitration Act

AARP Joins Fight To Preserve Right To Jury Trial

Are Trials Really That Important? 

A Call To Abolish Arbitration Clauses 

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One of the more tragic cases, my office is working involves a woman who developed pressure sores on her heels during an admission to a New Mexico nursing home.  Despite the fact that the woman was bed-bound, the facility took virtually no preventive measures to avoid pressure sores.

In fact, by the time the staff at the nursing home began to treat the wounds, much of her heels and feet were covered with necrotic tissue.  A systematic infection developed and both of the woman's legs required above-the-knee amputation to prevent the infection from spreading--- and probably save her life.

Pressure sores (also known as bedsores, pressure ulcers, or decubitus ulcers) are caused by pressure, which cuts off blood flow to parts of the body resulting in areas of injured skin and tissue.  The areas of the body most vulnerable to pressure sores are the heels, hips, and buttocks.  Persons who are bedridden, have limited mobility, or are confined to a wheelchair are especially at risk for pressure sores. 

As such, elderly nursing home patients are particularly vulnerable to pressure sores because of prolonged bed rest, limited mobility, and weakness.  Nursing home staff must turn residents who are bed ridden or have prolonged bed rest often enough so blood can circulate to areas that are under pressure. 

Pressure sores can be a very serious condition depending on how much skin and tissue is damaged.  Deep pressure sores can go all the way down to the muscle or even the bone.  Stage III pressure sores result when the tissue below the skin is damaged, causing a deep wound.  Stage IV pressure sores are the most serious pressure sores and involves destruction of large areas of skin accompanied by damage to the underlying muscle, bone, tendons, and joints.  If not treated properly, infection can set in and even require amputations.  Signs of infection include pus, bad smell, redness, swelling, tenderness, fever, and chills.

Surgical debridement (removal of damaged tissue) is one approach to treating serious pressure sores.  This process can be very painful because it involves using a scalpel or other instrument to remove all the dead tissue.  Some pressure sores reach a point where surgical repair is necessary.  The treatment usually involves harvesting tissue from another area of the body and using it to pad the wound.  In some situations, amputation is necessary. 

When pressure sores are not treated properly, tissue damage can spread and infection, including gas gangrene, can set in.  In severe cases (where surgical debridement, antibiotics, and oxygen treatment are unsuccessful), amputation of the limb might be required to prevent the infection from spreading further.  This is especially true in elderly people, especially those who are malnourished, because of poor blood flow. 

Amputation is the surgical removal of a limb or body part (arms, legs, feet, fingers, toes), usually to remove diseased tissue or relieve pain.  The amputation procedure is performed by an orthopedic surgeon in a hospital operating room under regional or general anesthesia.  The procedure varies depending on which limb is removed; however, all surgical amputations involve removing diseased tissue and constructing a stump, which will fit a prosthesis.  

The procedure for an above-the-knee amputation includes: first cutting the skin and muscle layers, then clamping the major blood vessels and cutting them, then cutting the bone with a bone saw, and finally, the muscles are stitched together over the bone and the skin is closed over the wound.   

The decision of how much of the limb to remove depends on how much tissue needs to be removed for proper healing, while saving as much of the healthy skin, blood vessels, and nerve tissue as possible for rehabilitative purposes.  One test that the surgeon performs to determine the health of the limb is the amount of blood flow to the affected region (measurement of blood pressure in the limb). 

As with other major surgeries, amputation carries with it the same risks including complications with anesthesia, blood loss, and blood clots; however, infection is the main complication following surgery.  Amputation is a painful procedure, requiring treatment with pain medication and antibiotics post-surgery, and a hospital stay ranging from five to fourteen days, absent further complications.  Following surgery, the newly formed stump must be moved often to encourage circulation, with physical therapy commencing as soon as possible. 

The rehabilitative process is a long process, especially for above the knee amputees.  The physical rehabilitation is often accompanied by grief counseling to help the patient cope with the sense of loss that comes with losing a limb.  Patients also often have phantom limb pain, which is very difficult to treat.  Amputation is a last resort for both physicians and patients, but in some cases, as with severe pressure sores (which are preventable), it becomes necessary.   

Resources:

MayoClinic.com – Pressure Sores

Merck – Pressure Sores

Encyclopedia of Surgery – Amputation

Vascular Web – Amputation

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Thousands of people visit Bed Sore FAQ each month to get information related to the care of bed sores (also referred to as decubitus ulcers, pressure ulcers or pressure sores) and to learn their legal rights after a bed sore develops during an admission to a nursing home or hospital.

Below are the 10 most popular Bed Sore FAQ's according to reader-generated traffic.  If you have a question related to bed sores or are interested in discussing legal options, please fill out the contact form, and I will respond to your inquiry personally.

1. What does a bed sore look like?
2. What are the stages of bed sores?
3. Are there limits on the financial recovery for a person who developed bed sores due to the negligence of a facility?
4. How does the use of the Braden Scale help in the prevention of bed sores?
5. What does a patients albumin level have to do with bed sores?
6. Is it possible to hire a lawyer to prosecute a bed sore case if I don’t have much money
7. What are nursing homes required to do to prevent bed sores?
8. Why is a colostomy needed for patients with severe bed sores?
9. What is a wound vac and how does it work?
10. What is surgical debridement of bed sores?

Still looking for more information?  Bed Sore FAQ is updated frequently and we have many new entries in the works.

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Texas Arlington Memorial Hospital was recently recognized for implementing a systematic program to reduce the number of patients with hospital-acquired decubitus ulcers.  The program resulted in a 63% reduction in pressure sores.  This hospital accomplished this by taking the following steps:

• Identifying decubitus ulcers on all new admissions
• Reducing use of diapers amongst patients
• Encouraging all staff to look for and document decubitus ulcers, even in their earliest stages
• Paying extra attention to patients who are bed bound or who's skin comes into contact with medical equipment like oxygen masks or tubing
• Implementing daily skin checks and intensive, hospital-wide skin checks on a quarterly basis to help the facility keep accurate tabs on how well its wound prevention program is working

Related Nursing Homes Abuse Blog Entries

Over 500,000 Adults Suffer From Bed Sores In Hospitals

Pressure Sores In Hospitals On The Rise

In For Rehab. Out With Bedsores.

Proper Wound Documentation

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A nursing home negligence lawsuit has been filed against Highland Health Care Center and its parent company  Covenant Care Midwest for their negligent care of a patient.  The lawsuit alleges that the patient was admitted to Highland Health Care Center on November 5, 2008 for physical therapy, following a total knee replacement surgery.

During the course of the prescribed physical therapy, the patient developed decubitus ulcers on his back and heel.  The decubitus ulcers became so severe that, surgery was required to help heal the wounds.

The nursing home negligence lawsuit claims Highland Health Care Center made numerous mistakes related to the patient's care and subsequent decubitus uclers, including:

• Failing to notify physicians of the patient's change in medical condition
• Failing to administer treatments prescribed by the physician
• Failing to make observations related to the patient's change in medical condition
• Failing to implement a pressure sore prevention program

The lawsuit is pending in Madison County Circuit Court.  Read more about this nursing home lawsuit here.

In with one problem, out with another...

While I certainly have no way of verifying the facts surrounding this nursing home lawsuit, the facts sound all too familiar.  In cases were nursing homes, hospitals rehabilitation facilities are hyper focused on a specific task, such as physical therapy, other patient needs can often fall to the wayside.  

Nonetheless, skilled nursing facilities have a non-delegable duty to take all feasible measure to prevent development of decubitus ulcers.  In this case, I have a hard time believing that if the facility was indeed performing the specified physical therapy on this patient.  If so, how did the decubitus ulcers develop?

Covenant Care

Covenant Care operates 50 facilities (skilled nursing, assisted living and select therapies) in California, Illinois, Indiana, Iowa, Nevada, Nebraska and Ohio. 

Related:

If a lawsuit or claim is filed against a facility where a person developed bed sores, what type of damages is the person entitled to?

What steps should I take before meeting with an attorney to discuss a case involving bed sores?

How long does it take for a lawsuit involving development of bed sores at a medical facility to be resolved?

What type of legal recourse does a person with bed sores have?

Resource:

Nursing Home Injury Laws

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A nutritious, balanced, and appetizing diet is important for all nursing home residents.  But it becomes essential for those suffering from pressure sores.  This is because a person with pressure sores needs to consume more calories per day that their healthy counterparts. 

Facilities need to calculate each patient’s total energy expenditure (TEE) in order to meet their nutritional needs.  TEE is composed of three components:

• basal metabolism, that is the number of calories needed to maintain a body at rest, which depends on age, sex, and body size;
• voluntary activity such as exercise; and
• energy expended to consume and metabolize food.

In times of injuries and stress, a body’s metabolic rate may increase, which in turn requires additional calories to compensate.  The extra calories provide the energy for the body to react to the stress of injuries and heal wounds.  So, while a normal person may need only 25-30 kcals per kilogram per day, a person with moderate illness or injury needs 30-35 kcals/kg, and a person with critical injury or illness needs 35-40 kcals/kg.  

Proper treatment for pressure sores must involve an assessment by a qualified dietitian who can figure out how many calories the patient should be consuming in order to heal and the best way to help the patient get the necessary calories from a balanced and appetizing diet.

Many facilities overlook, this crucial component to healing pressure sores.  Using the above nutritional guidelines, patients with advanced pressure sores would require the following daily caloric intake:

• 100 lbs.: 1,587 - 1814 daily caloric intake
• 150 lbs.: 2,381 - 2,721 daily caloric intake
• 200 lbs.: 3,175 - 3,628 daily caloric intake

In most cases, facilities must provide additional snack and nutritional supplements in order for patients to achieve this level of calorie intake.  If facilities fail to provide adequate levels of nutrition, the pressure sores are like to to advance and additional complications may develop.

Source: Nancy Collins, PhD, Rd, LD/N, FAPWCA, Why Calories Count: Proper Nutrition Fuels the Wound Healing Process.

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Harriman Care and Rehabilitation Center is under investigation after the grandson of a resident claims the facility provided such extraordinarily poor care that his grandfather developed advanced bed sores so big, 'you could stick your fist in'.  The grandson, William Brummitt claims the care Harriman provided to residents was so poor that it resulted in harm to both his grandfather, William Williams and his grandfather's roommate, Larry Waldo.

Brummitt claims the facility mistreated Waldo so severely that  he 'had laid in bed for seven days without a sheet being changed.'  'Flies were swarming around his left leg stump, where the femur was exposed," Brummitt added referring to Waldo's amputated legs.

Waldo died on June 25th, from "years of neglect to his health" according to a memo from the Roane County District Attorney. Nonetheless, the complaints from Brummitt prompted an autopsy to be performed on Waldo to help determine if the gangrene and subsequent leg amputations were necessitated by poor nursing care or an inevitable medical necessity.

Interestingly, Mr. Brummitt's mother, Bonnie Brummitt, is the power of attorney for William Williams and has attempted to block her son's contact with the nursing home.  Are William Brummitt's allegations accurate or are they nothing more than an unfair portrayal of care at this Tennessee nursing home?  

Read more about the allegations made against Harriman Nursing Home here.

Signature HealthCARE LLC

Signature HealthCARE is a Florida-based health care company, operating 21 skilled nursing facilities in Tennessee.  Harriman Nursing Home is a 180-bed facility in eastern Tennessee, that concentrates in both rehabilitation and long-term care.

Related Nursing Homes Abuse Blog Entries

Nursing Home Visits. An Opportunity To Conduct Your Own Inspection.

Bedsores: Are You At Risk?

A New Resource For Bed Sores: BedSoreFAQ.com

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I am proud to announce the latest spinnoff of the Nursing Homes Abuse Blog--- BedSoreFaq.com. Bed Sores are a horrendous condition that effect people in all demographics.  If you haven't seen a bed sore first hand--and I truly hope you never do--- BedSoreFaq will have photos, videos and diagrams of this gruesome medical condition.  

Most importantly, this site will bring needed attention to this condion. The more information individuals have about this topic-- the better prepared they will be to help themselves and their loved ones.

BedSoreFaq is a resource for those who have questions regarding bed sore prevention, treatment ---and ultimately legal rights of those who developed a bed sore due to the neglect of a nursing home or hospital.

Questions will be answered in an ethical and conscientious manner by myself as well as some of leading experts in the field of wound care and prevention.  Please check-in and watch this collection of material grow.  I invite you to submit questions and photos of loved ones who have suffered.

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In cases involving advanced bed sores (also called: pressure sores, pressure ulcers or decubitus ulcers), a wound vac or negative pressure wound therapy can be used to heal the bed sore.  A plastic bandage is used to cover the wound and a tube attached to a vacuum machine draws out moisture. The process can be painful, but the use of wound vacs drastically shorten the healing process and reduce risk of infection.  This is a useful video demonstrating wound vac process.

Nursing Homes Abuse Blog Posts On Bed Sores

Government Report Confirms Pressure Ulcers Harm All Nursing Home Residents; Regardless Of Race, Sex or Age

Pressure Sores In Hospitals On The Rise

Bedsores. Completely Preventable? Absolutely.

"The Nursing Home Says My Dad's Bedsores Were Unpreventable..."

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A colleague sent me this disturbing video of an advanced pressure sore.  A fair warning, this video is graphic and disturbing.  However, the reality is that pressure sores are a problem effecting individuals in nursing homes, hospitals, and long-term care facilities and can not be ignored.

Related Nursing Homes Abuse Blog Posts Related To Pressure Sores:

Nursing Homes With Higher Percentage Of Hispanic Residents Have Higher Rate Of Bed Sores

New Jersey Orders Use Of Pressure Relieving Mattresses In Nursing Homes

Pressure Sores In Hospitals On The Rise

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A research study concluded by researchers at Brown University concluded nursing homes with a higher Hispanic populations have higher rates of bed sores (also known as: pressure sores, pressure ulcers, decubitus ulcers) than facilities with less minorities.  The results are detailed in the Journal of the American Medical Association.

The researchers gathered information from the National Repository of the Minimum Data Set, a federally mandated assessment of all nursing home residents and from the Oscar Database System, a survey of all nursing home residents from the Centers for Medicaid and Medicare Services.  Additionally, the Brown study evaluated all nursing home residents over 65 who live in nursing homes in California, New Mexico, Texas, Arizona and Colorado.

The lead researcher of the Brown survey, Vincent Mor, chair of the Department of Community Health, conducted a similar survey in 2007 that concluded African Americans are more likely than whites to live in poor-quality nursing homes.  That study found the disparity of care received in predominately African American nursing homes to be worst in the Midwest.

Read more about the results of this nursing home survey here.

Bed Sores Are A Problem Facing All Nursing Home Residents

A bed sore is an area of skin that breaks down when you stay in one position for too long without shifting your weight. This often happens if you use a wheelchair or you are bedridden-- even for a short period of time (for example, after surgery or an injury). The constant pressure against the skin reduces the blood supply to that area, and the affected tissue dies.

A bed sore starts as reddened skin but gets progressively worse, forming a blister, then an open sore, and finally a crater. The most common places for pressure ulcers are over bony areas like the elbow, heels, hips, ankles, shoulders, back, and the back of the head.

Despite claims from the health care industry, bed sores are preventable with competent medical care.  Staff in nursing homes and hospitals must to an assessment of those individuals who are at heightened risk for development of bed sores and create a plan for their prevention.  Frequently, a care plan will include: frequent rotation to discourage sitting in one area for long periods, pressure relieving air mattresses and special enhanced nutrition diets.

Our Commitment To Minority Communities

One of the reasons there are higher rates of poor nursing home care amongst minorities is due to barriers in communication.  Nursing homes housing individuals should have staff to help communicate both physician orders to the residents and to communicate resident needs to physicians.  When there is a breakdown in communication, resident safety is jeopardized.

At Strellis & Field, we pride ourselves on our commitment to all minorities.  For more than 35 years, we have been honored to represent individuals and families of all races and ethnicity's.  We maintain a Spanish speaking staff and frequently work with translators to zealously represent individuals in the Polish, German, Italian, Japanese, Chinese, Korean and Vietnamese communities. 

We believe all people, regardless of their ethnic background, deserve the finest legal representation available.

Nursing Homes Abuse Blog Entries On Bed Sores:

Government Report Confirms Pressure Ulcers Harm All Nursing Home Residents; Regardless Of Race, Sex or Age

Incontinence Amongst The Nursing Home Population

Over 500,000 Adults Suffer From Bed Sores In Hospitals

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Ray Mullman at the South Carolina Nursing Home Blog recently wrote about one of the most progressive piece of legislation passed in years-- the mandatory use of pressure relieving mattresses in New Jersey Nursing Homes to help prevent the development of bedsores.

Unlike normal spring-filled mattresses, pressure relieving mattresses steadily inflate and deflate to reduce the amount of pressure and friction put on bony parts of the body prone that are prone skin break-drown and ultimately development of bedsores (also referred to as: pressure sores, pressure ulcers or decubitus ulcers). 

Under the terms of Bill S-1517, nursing home operators must to switch from regular mattresses to pressure-relief mattresses within three years. Nursing home owners would have one year from the bills enactment to begin phasing in the use of pressure relieving mattresses.

“While pressure redistribution mattresses may cost more up front than the standard spring mattresses, we cannot put a price on the continued health and wellness of our state's most vulnerable senior citizens,” said bill co-sponsor Sen. Bob Gordon (D-Bergen). “While these new mattresses alone won't make bed sores an ailment of the past, they will greatly reduce the incidence of bed sores, and make their treatment much easier on the dedicated nursing home staff.”

Bedsores continue to be a devastating problem for many nursing home and hospital residents.  If this law proves effective in New Jersey, it will be interesting to see if other states, or even Medicare, passes similar legislation.

Bed Sores In Nursing Homes

Government Report Confirms Pressure Ulcers Harm All Nursing Home Residents; Regardless Of Race, Sex or Age

Over 500,000 Adults Suffer From Bed Sores In Hospitals

Pressure Sore Video

Strellis & Field has experieced bedsore lawyers who can answer yor questions.  Contact us for a free, confidential consultation.  We can help.

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A report released by the Centers for Disease Control and Prevention confirmed what many nursing home residents and employees already know-- pressure ulcers are a tremendous problem encountered be nursing home residents of all races, sexes and ages.  The report,"Pressure Ulcers Among Nursing Home Resident: United States, 2004" analyzes information from the National Nursing Home Survey which is comprised of more than 14,000 nursing home residents from across the country.

In 2004, more than one in 10 nursing home residents had some form of pressure ulcer within the year.  Based on the total number of nursing home residents, that translates to more than 159,000 nursing home residents with pressure ulcers (otherwise known as bed sores, decubitus ulcers, or pressure sores).  Stage II pressure ulcers were the most common according to the survey.  Over 35% of the nursing home residents with pressure ulcers had more advanced-- stage III or stage IV ulcers that required special wound treatment.  Even younger nursing home residents, those commonly thought to be somewhat removed from the problem, are at risk according to the report.

The study demonstrates that while it is important to identify nursing home residents who are at risk for development of pressure ulcers and implement preventative techniques, no nursing home resident is immune from risk of developing pressure ulcers and the nursing home staff need to be tuned in to the factors related to pressure ulcer development and treatment.

About Pressure Ulcers

A pressure ulcer is an area of skin that breaks down when you stay in one position for too long without shifting your weight. This often happens if you use a wheelchair or you are bedridden, even for a short period of time (for example, after surgery or an injury). The constant pressure against the skin reduces the blood supply to that area, and the affected tissue dies.

A pressure ulcer starts as reddened skin but gets progressively worse, forming a blister, then an open sore, and finally a crater. The most common places for pressure ulcers are over bony areas like the elbow, heels, hips, ankles, shoulders, back, and the back of the head.

Despite claims from the health care industry, pressure ulcers are preventable with competent medical care.  Staff in nursing homes and hospitals must to an assessment of those individuals who are at heightened risk for development of pressure ulcers and development a plan for their care.  Frequently, a care plan will include: frequent rotation to discourage sitting in one area for long periods, pressure relieving air mattresses and special high nutrition diets.

Factors increasing the risk for development of pressure ulcers:

• Being bedridden or in a wheelchair
• Fragile skin
• Having a chronic condition, such as diabetes or vascular disease, that prevents areas of the body from receiving proper blood flow
• Inability to move certain parts of your body without assistance, such as after spinal or brain injury or if you have a neuromuscular disease (like multiple sclerosis)
• Malnourishment
• Mental disability from conditions such as Alzheimer's disease -- the patient may not be able to properly prevent or treat pressure ulcers
• Older age
• Urinary incontinence or bowel incontinence

Pressure sores are categorized by severity, from Stage I (earliest signs) to Stage IV (worst):

• Stage I: A reddened area on the skin that, when pressed, is "non-blanchable" (does not turn white). This indicates that a pressure ulcer is starting to develop.
• Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
• Stage III: The skin breakdown now looks like a crater where there is damage to the tissue below the skin.
• Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints.

Web Resources For Information On Pressure Ulcers:

Pressure Ulcer, Medline Plus

National Pressure Ulcer Advisory Panel

Staging Pressure Ulcers, Wound Care Information Network

Bed Sore FAQ

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Pressure ulcers (also called bedsores or pressure sores) are preventable with proper nursing care.  In fact, CMS (Centers for Medicare and Medicaid) has deemed the development of pressure ulcers to be so preventable in both acute and long-term care settings that it has stopped reimbursing for medical charges related to treatment of the ulcers.  This is useful video on the this topic.

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My office was recently retained by the family of a woman who developed pressure sores on her buttocks and vagina in a Chicago nursing home.  When asked, the family was unsure if their loved one was technically 'incontinent'.  After reviewing the woman's chart, it was obvious that the woman was incontinent and the nursing home failed to provide properly adequate cleaning and timely changes for this elderly nursing home resident. 

By some accounts, more that 50% of the people living in nursing homes or assisted living facilities may have some type of bladder or bowl control problems.  Although widely used, incontinence can be defined as the uncontrolled elimination of urine or fecal material from the body. 

Incontinence Is Not A Normal Part Of Aging

Despite its prevalence, incontinence is often treatable.  Any resident who has been deemed incontinent should be evaluated by a physician to determine if the cause of the incontinence is physical or psychological.  Once the cause is identified a combination of behavior modification and staff assistance may be of some help.  In other cases, medication or surgery may also help alleviate the incontinence issues.  Diapers or similar undergarments should only be used as a last resort.

Incontinent nursing home residents have an increased vulnerability for developing pressure sores (also called: pressure ulcers, bed sores or decubitus ulcers) for several reasons:

Nursing Home Residents In Denial Of Their Incontinence

Let's face it, there is perhaps nothing more humiliating to a senior than to admit to nursing home worker, whom he or she may not know, that they have lost their ability to control their bladder or bowels.  Consequently, some nursing home residents are hesitant to notify the staff to their situation and may wind up literally sitting in their own waste.

Inadequate Staffing To Properly Monitor And Change Incontinent Residents

All too frequently, nursing home staff try to implement a 'one size fits all' program for incontinent nursing home residents.  This approach is simply not acceptable.  Nursing homes must have a program in effect to monitor each residents changing needs and have staff available to change soiled residents.  Additionally, adequate levels of staffing should be in place to encourage residents who are able to use the toilet.

When urine or fecal material is held against the skin the damp, acidic nature of the wastes cause the skin to become weakened and susceptible to cracking and peeling--literally eroding the bodies natural defenses.  Proper maintenance of the skin, requires the skin to be kept dray and sanitized.  To minimize development of pressure sores, incontinent nursing home residents should:

• Be cleaned regularly with mild soap and lukewarm water
• Be moisturized daily
• Encourage the use of barrier products lotions
• Use proper turning techniques to minimize time spent in one location
• Use positioning devices to alive pressure from bony areas
• Keep the bed elevation as low as possible- this reduces pressure on the sacrum
• Keep residents clean and dry

For more information on incontinence and pressure sores in the nursing home setting:

Overview of Pressure Ulcer Management: An Expert Interview With Carol A. White MS, RN, ANPC, GNPC, DNP(c)

Incontinence in the Elderly: What a Caregiver Should Know

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By the time a pressure ulcer has progressed to Stage 4, the wound is deep the muscle and bone in the area is involved--usually decayed.   Frequently, infection can develop in the dead tissue impeding the healing process.

Advanced stage pressure ulcers need to be free of dead or damaged tissue in order to heal. Even with the most attentive medical care, some pressure ulcer's require surgical intervention.  Surgical Debridement is when a surgeon uses a scalpel to remove the dead tissue, bone and fluid from the area around the pressure ulcer. 

Debridement of the pressure ulcer may be accompanied by 'flap reconstruction'.  Flap reconstruction is when tissue is harvested from the persons body to cover the open wound.  The goal of the reconstruction is to improve the hygiene and appearance of the wound and and reducing the risk of further infection.

Surgical treatment of pressure ulcers has one of the highest complication rate of any surgical procedure.  Recovery from the procedure is time intensive and painful.  Therefore, the use of surgical intervention to treat pressure ulcers is usually considered to be a last resort.

Pressure ulcers are preventable.  If your loved one has developed a pressure ulcer while a resident of a nursing home, hospital or assisted living facility, contact the the team at Strellis & Field.  We can  help determine what parties may be at fault and advise you of your rights.

Resources For Pressure Ulcer Treatment

Emedicine: Pressure Ulcers, Surgical Treatment and Principles

Mayo Clinic: Bedsores. Treatments and Drugs

Related Bed Sore FAQ Entries:

What is mechanical debridement of bed sores?

What is chemical debridement of bed sores?

What is biological debridement of bed sores?

What is surgical debridement of bed sores?

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On the heels of the Nursing Homes Abuse Blog's recent discussion regarding an increase in hospital-related pressure sore cases, the Agency for Healthcare Research and Quality released a report further confirming the problem.  Perhaps most the most startling finding from the agency's report is that hospitalizations for bed sores (also called decubitus ulcers, pressure ulcers, pressure sores) have increased by more than 80% from 1993 to 2006.  This increase includes people who were admitted to the hospital because of pressure sores or developed them while being treated for another condition in the hospital.

Among the more disturbing 'highlights' in the report are:

• In 2006, there were 503,300 hospital stays with pressure ulcers noted as a diagnosis--an increase of nearly 80% since 1993.  The pressure ulcer stays totaled $11 billion in hospital costs.
• More than 90% of the pressure ulcer-related hospitalizations were intended to be for medical conditions unrelated to pressure ulcer treatment.
• Compared to stays for all other medical conditions, hospital stays related to pressure ulcers were more often discharged to and long-term care facility and more likely to result in death.
• 72% of adults hospitalized with a secondary pressure sore diagnosis were 65 or older.  In comparison 56.5% of adult patients had a principal diagnosis of pressure ulcers were 65 or older.
• Medicare was the biggest payer for hospital stays related to pressure ulcers- Medicare paid the bills for 3 out of 4 pressure ulcer stays.
• Paralysis and spinal cord injury were common co-existing conditions among younger adults hospitalized principally for pressure ulcers.

Don't let hospitals continue to provide inadequate treatment. Prevention of pressure sores needs to be a priority for hospitals.  If you or a family member developed a bed sore during a hospitalization, we can help.  Strellis & Field has successfully prosecuted bed sore cases for more than 30 years.

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An increasing number of number of pressure sore cases my office is working on involve pressure sores that have developed during a hospitalization.  What was once considered a sad symbol of poor nursing home care, is now increasingly associated with poor hospital care.  Many of our clients who enter a hospital for acute care, wind up extending their hospitalization due to the development of a pressure sore during their stay. 

Federal and State regulations require nursing homes to conduct a thorough assessment of all new admissions.  The assessment evaluates the individuals skin integrity and attempts to determine who is susceptible to develop of pressure sores.  This initial assessment is designed to help nursing home staff implement preventative pressure sore care.

Hospitals on the other hand, are not governed by the same regulations and consequently are not as attuned to pressure sore prevention.  Many hospitals fail to train their staff to identify pressure sore risk and implement policies for pressure sore prevention.

According to the Agency for Healthcare Research and Quality (AHRQ), the number of hospital patients who develop pressure sores (also known as pressure ulcers, bed sores or decubitus ulcers) has increased by 63% since 1996. 

Pressure sores are caused by unrelieved pressure to the skin which cuts off blood circulation to the area.  Hospitalized seniors are particularly vulnerable to development of pressure sores because many have limited mobility and may be bedridden.  Further increasing the risk of pressure sores amongst the elderly is the fact that many seniors have lost a considerable amount of muscle and fat that would normally help relieve the pressure in younger people.  Most pressure sores develop in areas where there is a 'bony' prominence.  Common areas where pressure sores develop are: the sacrum, coccyx, heels, elbows and ankles. 

Pressure sores are graded by their severity (1, 2, 3 and 4).  A stage 1 pressure sore may be a reddened area with some blistering.  By the time a pressure sore advances to stage 4, a deep wound has developed and may also involve organs and bones.  The AHRQ determined the average duration of a hospital stay for treatment of pressure sores to be 13 days, with an average cost of $37,500.

Pressure sores are preventable.  Hospital staff need to focus on patients factors and take necessary steps to assure patients remain free from pressure sores during their stay.  Among the steps hospitals need to take to prevent development of pressure sores are:

• Changes resident's positioning every two hours
• Use pressure relieving air mattresses
• Make sure patients are receiving proper nutrition
• Keep the resident clean and dry

We can help you

Don't let hospitals get away with providing substandard care. If you or a loved one has developed a pressure sore during a hospitalization, put our experience litigating pressure sore cases to work for you.  We have successfully recovered money for our clients from hospitals throughout the country. Contact the pressure sore lawyers at Strellis & Field for a personalized case consultation. All consultations are confidential.   We will come to you. 

Resource: About.com

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A lawsuit was recently filed against the Virgil Calvert Nursing and Rehabilitation Center by a former resident.  The lawsuit alleges the Illinois Nursing Home's neglect caused decubitus ulcers to develop a formers resident's body.  The female resident claims the ulcers have caused her to suffer severe pain, disability and extensive medical expenses related to their treatment.  Multiple violations of the Nursing Home Care Act, including failing to administer proper medication and providing the resident with necessary treatment to prevent the development of the decubitus ulcers are alleged

The lawsuit also names SW Management Company, the parent company of the nursing home. According to the lawsuit, SW Management Company was negligent because they failed to operate the home in a way that provided the plaintiff with adequate care.   Specifically, SW failed to properly supervise its staff and failed to terminate employees who were known to be careless, incompetent and unable to comply with the home's policies, the suit states.

Decubitus ulcers are a common problem facing nursing home residents.  Nursing homes have a duty to create and implement a care plan to address prevention of decubitus ulcers.  Careful adherence by the entire nursing home staff is essential to proper skin care.  For many nurisng home residents, already in a weakened physical state, a small decubitus ulcer may quickly advance to a large wound in a matter of days.

Read more about this nursing home lawsuit filed in St. Clair County Circuit Court here.

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A Seattle woman settled a lawsuit against the City of Seattle and Millennia home health care agency for $600,000.  The lawsuit alleged that the home health agency worker failed to follow the care plan specifically developed for people with Multiple Sclerosis.  The failure to follow the care plan lead to development of bedsores or pressure sores.  The home care worker was to shift the woman's weight every 15 minutes to prevent development of the sores.

Not only did the home care worker fail to prevent the pressure sores from developing, the worker failed to properly treat them.  Consequently, the woman was admitted to Providence Hospital for two months of medical treatment.  Two surgeries were performed to treat the pressure sores which were so far advanced, the infection had spread to the bone.  The pressure sores were also infected with MRSA, a potentially life threatening bacteria.

This sad incident highlights the need of home care nurses to properly implement care plans.  Care plans are developed by physicians and other medical professionals, that specifically lay out what medical treatment is to be provided.  If a home care nurse or agency fails to follow the care plan or fails to properly monitor the patient and an injury develops, they have liability similar to that of nursing homes. 

Read more about this case of nursing neglect by a home care agency here.

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A blog reader recently wrote, "The nursing home says my dad's bedsores were unpreventable. Is this the case, or are some bedsores an unavoidable part of living in a nursing home?"

No!  The nursing home is lying to your face is is probably trying to cover their own.  Bedsores, also called pressure sores or decubitus ulcers, are preventable--with proper screening, early detection, and staff involvement.   Bedsores are a widespread problem in nursing homes and hospitals. The development of of bedsores in nursing home patients is really a reflection of poor nursing care than an inevitable part of of the aging process.

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This week my office was contacted by the family of a man who had a stage IV bedsore on his head.  The man was a resident at a well-known Chicago nurising home for several years.  Bedsores are caused by unrelieved pressure or friction on a patients body.  If left untreated, the bedsores can develop from a minor skin irritation to a major would quickly.  Due to their 'open' nature, bedsores can easily become infected.  Bedsores are graded according to their severity, I, II, III and IV, with a stage IV being the most severe.

What makes this situation uniquely horrific is that bedsores generally develop in areas of the body where pressure relief is not always possible-- the buttocks, back or heels.  Because most nursing home residents lay in bed with pillows and and propped up for meals and washings, development of a bedsore on the head is a particularly frightening finding.

The development of a bedsore on the head essentially screams out the fact that this nursing home could care less about this person.  Even though this resident was bed-bound and fed through a feeding tube, the development of a pressure sore on his head should have been noticed if at no other time than when the staff changed the sheets?  This facility should be ashamed of itself and every person who works there.  I will keep you posted as to developments in this incident involving a new low in nursing home care.

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A client emailed me this disturbing You Tube video on pressure sores.  The video is graphic, but demonstrates the horrific pressure sores that may develop without proper nursing care.  The video has photos of:

• Pressure sores on hips
• Pressure sores on buttocks
• Pressure sores on feet
• Pressure sores on heels
• Pressure sores on elbows
• Pressure sores on head
• Pressure sores on back
• Pressure sores on neck

As the narrator says, if you have a pressure sore, it is likely the result of neglect.  If this pressure sore developed in a nursing home, long-term care facility or hospital, you likely have a case against them for improper care and are entitled to damages for the resulting medical treatment and pain and suffering amongst other legal rights.

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Nursing home visits are great for both residents and their friends and families.  Everyone is usually happy to see each other and discuss current world topics, the weather, baseball or food.  However, don't let the smiles distract you from what should be a secondary reason for visiting friends and family members in nursing home--doing a mini inspection. 

I'm not talking about getting up on the roof of the nursing home and looking at the quality of the shingles or heading down to the basement to look at the hot water heater.  Rather, when visiting don't be shy about prodding around both the facility itself and on your loved one.  Look at the: cleanliness of the facility, look at the food, pay attention to the temperature of the room, look for familiar faces, look at the schedule of activities, chat with the staff--keeping track of all the small parts of your loved one's environment is the best it can be.

If your family member is bed-bound, pull the sheets back and peek under the robe.  Is everything clean?  Are their any dry or cracked areas of skin?  Is there any unpleasant smell?  Does everything look ok?  Even the sharpest elderly may lack sensation in areas of their bodies to detect skin irregularities.  If something looks wrong-- it probably is.  Early detection of potentially deadly conditions, such as pressure sores, may save your loved one from pain and embarrassment down the road.  You're not being a pest, you're being a caring friend or family member looking out for your loved one's best interest.

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This is not a word association game.  This summarizes my day yesterday.  A world of extremes.

I began my day yesterday going to Whole Foods to pick up a sandwich to propel me on trip to see a client (I hate eating fast food--long before I saw the above movie).  The store had just opened and as I walked to the back of the store where they keep the prepared sandwiches, I was blown away quantity and quality of the meat, chicken and fish behind the glass cases.  The different products were looking fresh and inviting as they sat lined up in perfect rows.  I guess it really stood out yesterday because there were so few other people in the store to distract me.  Everything was pristine.

I then got on a plane to meet with a client and her family.  My client, Nellie, an 82-year-old woman had developed a stage 4 pressure sore on her coccyx within three weeks of her admission to a nursing home. The pressure sore had gotten so bad that she had gangrene in the wound and was transferred to a special wound care wing of the hospital.  

Two to a small room, laid the mostly elderly patients, on their sides faced towards the windows as the staff tried take pressure off of pressure sores on their backside.  The smell of waste and rotting flesh was obvious despite the facilities attempt to cover up the scent with room sanitizers.  Most were incontinent and laid in soiled beds while the hospital tried to get by with an abbreviated weekend staff.  Even with an involved family such as my client's, the people sit and wait for the staff to tend to their needs.  A priest darted around the hall into and out of rooms--it was obvious by the speed at which her worked many of these people were could not spare more than a few seconds.   This was no Whole Foods.

I then got back on the plane and went home and turned on the television.  "Fast food nation' was on. 'Fast food nation' describes how a fast food restaurant chain's desire for bigger, cheaper hamburgers leads a meat packing plant to cut corners and allow fecal material into the hamburger meat.  The restaurant begin to panic when they consider how the public may react if they learn of the contaminated meat.

Why do we insist upon clean well presented food in restaurants and stores yet allow many in our elderly population to sit in facilities where livestock gets treated better?  Can you imagine what would happen to Whole Foods sales if they replaced the richly colored meat with rotting carcasses?

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'Sepsis' is a bacterial infection in the bloodstream or body tissues commonly found in people with advanced bed sores (also referred to as pressure ulcer, decubitus ulcer or pressure ulcer).  In order to make a diagnosis of sepsis, at least two of the following must occur: a heart rate above 90 beats per minute, hyperventilation (more than 20 breaths per minute) and white blood cell count below below 4000 cells/mm.

Frequently, people use the term sepsis to describe 'severe sepsis' and 'septic shock.'  Severe sepsis is used to describe people who have organ dysfunction following a diagnosis of sepsis.  People diagnosed with septic shock have sepsis with hypo-tension (abnormally low blood pressure).

Sepsis is a common medical condition; it accounts for:

• 1-2% of all hospitalizations
• 25% of all intensive care visits
• 10th most common cause of death

Causes

Exposure to different microbes (germs) can cause sepsis.  Sepsis is most commonly caused by bacteria, but it can also be caused by exposure to virus and fungi.  Many people develop sepsis after experiencing infections such as: pneumonia, meningitis, cellulitis, urinary tract infection.  Amongst nursing home residents, people who have pressure sores and amputations are particularly vulnerable.

Treatment

In order for treatment to be most effective, it must be implemented as soon as the diagnosis is made.  Generally treatment consists of antibiotics and surgical drainage.  Nutritional supplements are also suggested as treatment for sepsis.

Related:

Is sepsis related to bed sores?

Lawsuit Alleges: One Week In The Nursing Home Results In Significant Deterioration Of Pressure Sores & Sepsis

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Development of a pressure sore can be devastating for both the individual and his or her family. Frequently, there are questions as to how to properly treat the wound. Before an adequate treatment plan can be developed, it is important to conduct a thorough assessment of the wounds. Below is an assessment compiled by Donna Sardina, RN, MHA, WCC President, Wound Care Education Institute that appeared recently on the McKnight's website:

What should be included in wound documentation to support appropriate caregiving measures?

Assessment and documentation should be carried out at least weekly. The exception is when there is evidence of deterioration, in which case both the wound and the patient's overall management must be reassessed immediately.

When wound complications or changes in wound characteristics are noted, documentation should be completed daily until the wound is stable. Documentation should include at a minimum:

Assessment findings–Type of wound, staging, correct anatomical location, measurements; presence of tunneling/undermining; drainage (amount, color, consistency, odor); wound base tissue (slough, eschar, granulation, epithelialization); wound edges (curled, callused, macerated, detached);  periwound (intact, scaly, induration, edema, redness, warmth, color).

Symptoms of infection–Fever, increased white count, hypotension, general malaise, redness, swelling, induration, streaking, purulent drainage, temperature of surrounding tissue.

Pain–Intensity, location, quality/patterns of radiation and character, duration, variations, patterns, alleviating and aggravating factors, current and past pain management plan, effects of pain, pain goal, physical exam of pain.

If a review of your family member's medical chart does not properly address the above documentation, it is unlikely they are receiving the care necessary to heal from the pressure sore or wound.

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An Ohio woman is bringing a lawsuit against Mansfield Memorial Homes for improper care resulting in bedsores.  Dorothy Modcap, 64, sought skilled rehabilitation for a fractured hip following an auto accident.  What she got instead was a bedsore and infection.  According to her attorney, no preventative measures were put in place to prevent the development of the bedsores.  Bill Campell, Modcap's attorney states:

When you have somebody at that age who is in a wheelchair already, you really have to put interventions in place to make sure the person is turned frequently, or a skin breakdown can develop that turns into a very nasty bedsore.  It is clear that she had absolutely no skin breakdown until she went into the nursing home.

According to public records, Mansfield Memorial Home was recently cited for nine health care violations and five fire safety deficiencies.  Read more about this lawsuit here.

The facts surrounding the above incident are familiar to most nursing home residents who suffer from pressure sores.  Nursing homes must identify people who are susceptible to bedsores and implement care plan for their prevention.  Even the most active and healthy nursing home residents should have preventative care plans in effect.  Failure to implement such a plan represents nursing home neglect.

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New Medicare and Medicaid guidelines will soon put pressure on nursing homes and other long-term care facilities to provide better wound-care for their residents.  Under the revised pressure ulcer regulations (F-314), facilities will be unable to receive reimbursement from Medicare or Medicaid if the agencies deem the pressure ulcer to be avoidable.

According to McKnight's Long Term Care News, up to 28% of all residents in long-term care facilities suffer from pressure ulcer's.  The cost for treatment of pressure ulcers is estimated to be more than $1.3 billion.

Under the current system, nursing homes and long-term care facilities may submit charges for pressure ulcer care to Medicare and Medicaid.  Essentially, there is no economic incentive to provide preventative pressure ulcer care for most facilities.  The new guidelines will put pressure on nursing home owners and administrators to readdress the way they provide care, or they their bottom lines will suffer.

Most facilities wound management guidelines are not adequate.  'Most of the standards are below what is necessary to decrease the incidence of wounds and manage current wounds," according to wound care expert, Margaret Bryant, PT.

The first step in providing better wound care is for facilities to provide better training for their staff.  'Preventing and managing pressure ulcers takes a very aggressive approach--one that requires facility wide buy-in and multi-disciplinary involvement,' says Heather Hettrick, PT, PhD, a director at American Medical Technologies Inc.

Even the most basic pressure ulcer prevention techniques are ignored or done improperly.  In order to prevent pressure sores on heels, off-loading boots are the best choice.  However, the boots must be properly sized and adjusted in order to successfully keep the heel in the air as the boots are intended.  Improperly used boots are ineffective.

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The incidence of bedsores (or pressure sores or decubitus ulcers) is shockingly common in many nursing homes, hospital and assisted living facilities.  Determining who may be at risk for developing this potentially devastating condition is important to preventing the development of them in the first place.  If a family member has one or more of the conditions below they are at an increased risk for development of bedsores.  A daily monitoring of their condition should be done as the first step of prevention.

The following are risk factors identified by The Mayo Clinic:

Age: If you are over 70, you are at an increased risk for development f bedsores.  Older adults tend to have thinner skin than younger people do, making them more susceptible to damage from minor pressure. They're also more likely to be underweight, with less natural cushioning over their bones. And poor nutrition, a serious problem among older adults, not only affects the integrity of the skin and blood vessels but also hinders wound healing. Even with optimum nutrition and good overall health, wounds tend to heal more slowly as you age, simply because the repair rate of your cells declines.

Living In A Nursing Home:  In general, nursing home residents have higher rates of bedsores than do people who are hospitalized or cared for at home, in part because nursing home residents may be especially frail. On the other hand, rates are even higher for hospitalized patients who are immobilized, such as people who are recovering from a hip fracture or who are in a coma.
Lack of pain perception. Loss of sensation is usually due to spinal cord injuries or disease. An inability to feel pain means you're not aware when you're uncomfortable and need to change your position or that a bedsore is forming.

You Are Skinny:  You often lose weight when you're sick or hospitalized, and muscle atrophy and wasting are common in people living with paralysis. In either case, you lose fat and muscle that help cushion your bones. Some experts say the best way to prevent skin breakdown is to have at least 2 inches of muscle over bony areas.

Malnutrition: You're more likely to develop pressure sores if you have a poor diet, especially one deficient in protein, zinc and vitamin C. You're also more likely to have recurrent pressure sores, more severe infections and slower healing wounds than are people with healthier diets.
Urinary or fecal incontinence. Problems with bladder control can greatly increase your risk of pressure sores because your skin stays moist, making it more likely to break down. And bacteria from fecal matter not only can cause serious local infections but also lead to life-threatening systemic complications such as sepsis, gangrene and, rarely, necrotizing fasciitis, a severe and rapidly spreading infection.

Diabetes: Because certain health problems such as diabetes and vascular disease affect circulation, parts of your body may not receive adequate blood flow, increasing your risk of tissue damage. And if you have muscle spasms (spastic paralysis) or contracted joints, you're subject to repeated trauma from friction and shear forces.

Smoking Smokers have a higher incidence of pressure sores than nonsmokers do. They also tend to develop more severe wounds and to heal more slowly, mainly because nicotine impairs circulation and reduces the amount of oxygen in your blood. The risk increases with the number of years and cigarettes smoked.

Aside from living in a nursing home, many nursing home residents also have a number of other risk factors for developing bedsores.  There for the nursing home staff needs to monitor all residents on a daily basis to prevent bedsore development.  Further, identification of a bedsore at an early state is crucial to its treatment.
 

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A client's daughter forwarded this link to me regarding pressure sores (or similarly called pressure ulcer, decubitus ulcer or bed sore). This is a thorough discussion of the subject and is useful to all who have pressure sores or who may be at high risk for developing them. This article appeared on the CNN website.

Bedsores (Pressure sores)
From MayoClinic.com
Special to CNN.com

Bedsores, more accurately called pressure sores or pressure ulcers, are areas of damaged skin and tissue that develop when sustained pressure -- usually from a bed or wheelchair -- cuts off circulation to vulnerable parts of your body, especially the skin on your buttocks, hips and heels. Without adequate blood flow, the affected tissue dies. Although people living with paralysis are especially at risk, anyone who is bedridden, uses a wheelchair or is unable to change positions without help can develop pressure sores. Pressure sores can develop quickly, progress rapidly and are often difficult to heal. Yet health experts say many of these wounds don't have to occur. Key preventive measures can maintain the skin's integrity and encourage healing. Signs and symptoms

Pressure sores fall into one of four stages based on their severity. The National Pressure Ulcer Advisory Panel, a professional organization dedicated to the prevention and treatment of pressure sores, has defined each stage as follows:

Stage I. Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.

Stage II. At this point, some skin loss has already occurred -- either in the epidermis, the outermost layer of skin, in the dermis, the skin's deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.

Stage III. By the time a pressure ulcer reaches this stage, it has extended through all the skin layers down to the muscle, damaging or destroying the affected tissue and creating a deep, crater-like wound.

Stage IV. In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections. If you use a wheelchair, you're most likely to develop a pressure sore on: Your tailbone or buttocks Your shoulder blades and spine The backs of your arms and legs where they rest against the chair When you're bed-bound, pressure sores can occur in any of these areas: The back or sides of your head The rims of your ears Your shoulders or shoulder blades Your hip bones, lower back or tailbone The backs or sides of your knees, heels, ankles and toes.

Causes

You shift in your chair during meetings, fiddle with the radio when driving, turn a dozen times in your sleep. Every day, without thinking, you make hundreds of subtle postural adjustments that help stave off problems arising from inactivity. But for people immobilized by paralysis, injury or illness, those problems -- including pressure sores -- are a constant threat. Pressure sores usually result from sustained pressure on your body. They're especially common in areas that aren't well padded with muscle or fat and that lie just over a bone, such as your spine, tailbone (coccyx), shoulder blades, hips, heels and elbows.

Because your skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or bed, blood flow is restricted. This deprives tissue of oxygen and other nutrients, and irreversible damage and tissue death can occur. Though the affected tissue may die in as little as 12 hours, the injury may not be apparent for days or even weeks. In some cases, the pressure that cuts off circulation comes from unlikely sources: the rivets and thick seams in jeans, crumbs in your bed, wrinkled clothing or sheets, a chair whose tilt is slightly off -- even perspiration, which can soften skin, making it more vulnerable to injury.

Other causes of pressure sores include: Friction. Frequent shifts in position are the key to preventing pressure sores. Yet the friction that occurs when you simply turn from side to side can damage your skin, making it more susceptible to pressure sores. Shear. This occurs when your skin moves in one direction, and the underlying bone moves in another. Sliding down in a bed or chair or raising the head of your bed more than 30 degrees is especially likely to cause shearing, which stretches and tears cell walls and tiny blood vessels. Especially affected are areas such as your tailbone where skin is already thin and fragile.

Resource:

Bed Sore FAQ

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Today I met with a family who's mother recently died from sepsis after a month stay at a Chicago-area hospital.  The family hesitantly confided in me that their mother had a gaping hole on her buttocks at the time of her death.  While the family obviously was not responsible for their mother's care when she was in the hospital; they had a sense of responsibility because there is a stigma about bedsores.

Once you see how gruesome an advanced stage bedsore can be, you will never forget it.  Decubitus ulcers, commonly known as bed sores, may start in a small area and look similar to a bruise.  If left untreated or gone unnoticed, the bed sores may rapidly develop into literally deep holes in the body.  Bedsores are generally categorized I, II, III and IV.  A stage IV bedsore may involve dead skin, a putrid smell, and a tunneling which often times results in internal organs becoming visible.

Stages of pressure sores

To some, bedsores are associated with the poor and unwanted.  In reality, they are commonplace at many hospitals and skilled nursing facilities.  Wherever they develop it is unfortunate and completely preventable.  Upon admission, each facility should do an assessment to determine the potential for each resident / patient to develop bedsores.  The failure to do a five minute bedsore assessment at many facilities only leads to bigger problems developing more quickly.

I came across this New York Times article discussing the team-approach required to address the prevention of bedsores.  Clearly, every person responsible for a resident's care must keep in mind of the real possibility that bedsores may develop if one member of the team drops the ball.

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