Ms. EB, a frail 82-year-old woman admitted to a long-term care facility, had a complex medical history that included diabetes, extensive heart disease, ischemic strokes with left-sided weakness and dysphagia, dementia, kidney disease, anemia, chronic Clostridium difficile infection, and obesity. Her condition was guarded at best on admission, and she had a feeding tube for nutrition secondary to dysphagia. Despite these challenges, she survived two years at the facility. She had been in the hospital at least four times in her last year, the latest involving respiratory failure with intubation twice. Her kidneys had failed, requiring hemodialysis. She endured multiple sepsis infections with multidrug-resistant Acinetobacter and vancomycin-resistant enterococci, as well as recurrent C. diff infections with continued severe diarrhea. The family refused palliative care involvement because they refused to believe that their mother was nearing end of life. Numerous practitioners in multiple facilities charted that the family was unrealistic in their expectation that she would recover. Even toward the end of the last hospitalization, the family refused to discuss hospice care. The patient eventually developed a deep and necrotic stage 4 pressure ulcer that needed surgical debridement and became the focus of a lawsuit; she died almost two years after her initial admission to the facility.
With her multiple comorbidities and advanced age, there can be little doubt that the development of the ulcer was part and parcel of end-of-life skin failure. But to prevail, the facility had to show that they indeed met the standards of care related to pressure ulcer care.
Does any of this sound familiar? How would your facility stand up to legal scrutiny, and could it prevail in a lawsuit? As 90% of all cases do, this one settled out of court, but for a substantially smaller amount than plaintiff was seeking, so it was considered a victory for the defense. What had the facility done right? Fortunately, the documentation was good, detailing the multiple interventions that were instituted and addressing the many issues that plaintiff attorneys frequently target in a pressure ulcer lawsuit. The facility's defense included the following areas of care:
We now know that not all pressure ulcers are avoidable, especially with end-of-life issues and organ failure. But we still will be held accountable for skin breakdown and pressure ulcers and be liable for lawsuits if proper care and documentation is not present. How would your facility stack up?
About the Author
Heidi H. Cross, MSN, RN, FNP-BC, CWON, is a certified Wound and Ostomy Nurse in Syracuse, NY. She has extensive experience caring for wound and ostomy patients in acute care as well as in long term care facilities. Currently, she is employed by CNY Surgical Physicians consulting for nursing homes in the Syracuse area, and has served as an expert witness for plaintiff and defense attorneys.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.