Nursing Homes Abuse Blog - By Jonathan Rosenfeld

Contrary to what some medical facilities suggest, the development of pressure sores during an admission to a facility is not an inevitable part of getting older or something that simply coincides with some medical conditions.  Rather, pressure sores are overwhelmingly the result of inattentive care on the part of the facility.

After all, the prevention of pressure sores is not rocket science!  

Basic preventative measures implemented by nursing homes, hospital and other types of long-term care facilities can significantly reduce the incidence of pressure sores.  Well-known preventative measures include:

• Turning patients at regular intervals
• Keeping patients clean and dry
• Ensuring patients are kept well nourished and hydrated
• Utilizing the latest advancements in pressure reduction technologies-- cushions, mattresses ect.

Particularly in patients who may already be disabled or elderly, the development of pressure sores is an especially cruel complication that can cause pain, disability and significantly increase the chances of patients acquiring complex complications such as: sepsis, gangrene or osteomyelitis.

With years of experience representing patients and families in cases involving the development of pressure sores at medical facilities and other types of institutions, Rosenfeld Injury Lawyers understands the troubling issues as they weigh on the individual and family.  

Should the need arise to seek legal recourse in relation to the development of pressure sores, we invite you to review our expanded Pressure Sore Injury section to our firm website with pages devoted to: Pressure Sores in Nursing Homes, Pressure Sores in Hospitals, Pressure Sores in Assisted Living Facilities, Stages Of Pressure Sores and information on frequent complications such as: Sepsis, Osteomyelitis, Gangrene, Necrotizing Fasciitis and Death.

• Turning patients 

• Using pressure reducing mattresses and pads (pressure relieving devices) 

• Keeping residents clean and dry 

• Providing adequate nutrition and hydration 

• Performing skin checks 

• Bone/join infections (osteomyelitis, the infection spreads into your bones and can cause damage to tissue and cartilage) 

• Cellulitis (infection of the skin’s connective tissue, spreads quickly and can cause sepsis and meningitis, two life-threatening complications) 

• Sepsis (bacteria enters your bloodstream, life-threatening condition which can cause organ failure and shock) 

• Cancer (of the skin’s squamous cells)
• Death

• 45,500 hospital admissions had pressure ulcers as the primary diagnosis 
•  1 in 25 hospitalizations related to pressure sores resulted in death during the admission 
•  457,000 hospital admissions had pressure ulcers as the secondary diagnosis 
•  1 in 8 of these admissions ended in death 
•  Pressure ulcer related hospitalizations also cost more than the average hospital stay ($16,755-20,430 as opposed to about $10,000) and requires a longer hospital stay (13-14 days as opposed to only 5 days) 

'Under-staffing' and 'under-funding' are just several of the underlying reasons alleged to contribute to the development of a patient's bed sores (or decubitus ulcers, pressure ulcers or pressure sores) during an admission to a Missouri nursing home.  

The nursing home negligence lawsuit, filed by my colleague Attorney David Terry, is filed on behalf of a deceased nursing home patient and alleges the nursing home (Parkwood Skilled Nursing and Rehabilitation Center) and its various management companies operated the facility in a manner where money necessary for essential patient-care services was diverted away from the the facility to the benefit of the facility owners.

The subject of the lawsuit, Nellie Wilks, was an elderly woman who was admitted to Parkwood Skilled Nursing and Rehabilitation Center on July 7, 2008.  At the time of her admission, Ms. Wilks suffered from various medical conditions and was very much dependent on the staff at Parkwood for providing care for her daily living needs.  Despite her maladies, Ms. Wilks did not have any type of pressure sore on her body.

Also at the time of her admission, the staff at Parkwood conducted an assessment of Ms. Wilks needs and determined her to be at risk for developing bed sores, due to her limited mobility, incontinence of bowel and bladder and need for staff assistance with all of her daily living needs.

The failure on the part of the staff at Parkwood (as well as the owners' failure to provide staff with the means to do their job) to properly implement Ms. Wilks' plan of care is alleged to be responsible for the development of a stage IV pressure sore on Ms. Wilks' sacrum. The wound's advanced nature, necessitated a medical procedure known as a diverting colostomy and extensive medical care until her death on October 26, 2008.

The lawsuit against Parkwood specifically alleges the facility failed to provide adequate care to prevent the following:

• Pressure sores
• Malnourishment
• Development of a urinary tract infection
• Osteomyelitis
• Severe pain

Sadly, many nursing home patients are currently suffering horrible pain and embarrassment due to bed sores.  The overwhelming majority of bed sore cases are the result of the facilities failure to properly implement plans of care.  In cases where a bed sore developed during an admission, facilities can be held responsible for the resulting pain and loss of dignity and medical expenses.  

Our nursing home attorneys are available to discuss your situation with you and advise you of your legal rights.  All consultations are confidential and no fee is ever charged unless there is a recovery for you. (888) 424-5757

Related:

Nursing Home Resident Dies From Improperly Treated Pressure Sores During Short Rehab Stay

New York jury awards $19m to family of man who developed advanced bed sores during nursing home admission

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

Angela Thompson v. Parkwood Skilled Nursing and Rehabilitation Center (pdf)

Bed Sore FAQ's

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

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 (Arizona), 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

Bed Sore Resources

Bed Sore Treatment Specialists

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.

After a one week stay at Caseyville Nursing and Rehabilitation (IL), 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 (also referred to as: severe sepsis, sepsis infection, septic shock, severe sepsis, septicemia), 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

Bed Sore Resources

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 (also referred to as: severe sepsis, sepsis infection, septic shock, severe sepsis, septicemia) 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