In particular, surveyors discovered the following alarming situations at the Southern Illinois facility:

• The facility failed to have written procedures regarding patient care (Section 350.620 Resident Care Policies)
• Edwardsville failed to provide skilled nursing services that are required to maintain each patient's health-- when the facility failed to identify signs of physical and psychological illness that were apparent in one of the patients (Section 350.1210 Health Services)
• Delaying the implementation of medical care that was necessary for patients who need the services of a physician, licensed nurse or professional nurse
• Failed to maintain adequate patient records pursuant to Section 350,1610
• Neglecting a patient in violation of Section 2-107 of Illinois' Nursing Home Care Act

The above violations came to light following an investigation of an extremely sick patient suffering from uncontrolled diabetes and severe mental illness amongst other maladies.

Nursing home surveyors focused on the fact that the patient at issue was admitted to a hospital emergency room after an extended illness Edwardsville Terrace.  The unidentified patient was admitted to the emergency room with the following diagnosis:

1. Septic shock
2. Dehydration
3. Cardiomyopathy
4. E. Coil
5. Sepsis
6. Right nephrolithiasis causing E. Coli sepsis
7. Chronic ear infection
8. Hypertriglycerdemia

The nursing home patients acute illness necessitated extensive medical treatment and extended hospitalization. While reviewing the patient's chart from Edwardsville Terrace, a gross lack of documentation lead the surveyors to believe the facility failed to provide essential medical care.

Certainly, this survey should give patients and their families cause for concern; due to the fact that this facility failed to meet the basic needs of this patient.  Hopefully, the disclosure of poor care (as well as the $20,000 fine imposed against this facility) will cause Edwardsville to improve their documentation and re-commit themselves to providing necessary care for all of their patients.

Nonetheless, I am sure that this incident is not isolated.  If you believe your loved one was mistreated, abused or neglected at Edwardsville Terrace, I would honor the opportunity to speak to you about the situation and your legal options.

Related:

Diabetic Ketoacidosis Is An Under-Appreciated Danger Facing Many Nursing Home Patients

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

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

Improper Transfer Leads To Broken Arm

First Quarter 2010 Illinois Nursing Home Violations Released

Physically, nursing home patients suffering form incontinence tend to suffer higher rates of medical complications than their peers due to the fact that they may suffer from more rapid de-conditioning, dehydration (because they are scared to increase their fluid intake), higher rates of falls (rushing to get to the toilet) and perhaps most problematic-- an increase in the rate in development of bed sores.

Bed sores, also referred to as: pressure sores, pressure ulcers or decubitus ulcers, are wounds that develop when a nursing home or hospital patient remains in one position for an extended period of time.  Patients suffering from bowel or bladder incontinence are at a heightened risk for developing bed sores due to the caustic nature of feces and urine.  When the urine and feces remains in contact with the skin, the skin breaks-down faster than under 'normal' conditions.

I was happy to read about a new approach to treat urinary incontinence currently being implemented at Golden Living at Phoenixvile, a Pennsylvania nursing home.  The nursing facility utilizes a team-approach to analyze and implement an treatment plan for each patient according to their physical and cognitive abilities.

Typical urinary incontinence treatment plans include:

• Strengthening exercises for the pelvic region, hips and abdomen
• Behavior modification programs to help patients relax
• Modifying medication dosages and types
• Simple, practical methods such as: scheduling bathroom trips, modifying clothing to make removal easier and changes in eating routines

The urinary incontinence program appears to be working. "Loss of bladder control is not just a condition of the aging process," according to Roxanne Higgins, Rehabilitation Coordinator at Golden Living at Phoenixville.  "Our UI programs can help successfully treat many patients and help them enjoy more active lives."

Related:

Are incontinent patients at an increased risk for developing bed sores?

In order to prevent pressure sores, it is important to analyze the factors that make a person susceptible to developing them.

6 Most Common Causes Of Bed Sores & How Caregivers Can Help

Lack Of Cleanliness & Incontinence Contributes To Development Of Bed Sores In Nursing Home Patients

Incontinence Amongst The Nursing Home Population

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

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

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

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?

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.

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.

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

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.

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

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?

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.

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.

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

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:
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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.

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?

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?

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

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