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Legal Perils and Pitfalls of Wound Care: Nutrition Assessment, Support, and Documentation, Part 1

Pressure injury risk and development are multifactorial, individualized processes. Each patient presents with a unique set of circumstances and needs. In looking at charts for attorneys to determine whether standards of care related to pressure injuries have been met, key elements include turning and positioning measures, support surfaces, mobility, proper and timely assessment of risk factors and wounds, physician communication and notifications, communication with family, proper wound treatments, and nutrition assessment and measures.

Nutrition in Pressure Injury Lawsuits

Nutrition plays a huge role in pressure injury lawsuits. The highest awards in lawsuits for pressure injuries caused by a single factor pertain to inadequate nutrition, for good reason: protein-energy malnutrition is a key risk factor for pressure injury development. Adequate calories, protein, fluids, vitamins, and minerals are needed by the body to maintain tissue integrity and prevent tissue breakdown. Lack of adequate protein and calories, particularly, can lead to breakdown of muscle tissue for energy and lead to loss of lean body mass. The body tips toward a negative nitrogen balance, a catabolic state, and so cannot build up enough protein to heal wounds and prevent further breakdown. This continues in a downwards cycle unless this trend can be reversed and nutrition can be supported, leading to an anabolic state.

Pressure Injury Healing and Oral Nutritional Supplements Enriched With ArgininePressure Injury Healing and Oral Nutritional Supplements Enriched With Arginine

Nutrition Standards of Care

So, what are the standards of care when it comes to nutrition? Even though I am NOT a dietitian, I am aware of the standards. Much of what I look for when reading charts is based on the 2019 guidelines of the National Pressure Injury Advisory Panel (NPIAP). Here are some points to ponder:

  1. Was nutrition screening performed on admission, by using a simple, valid and reliable nutrition screening tool? This can be done by any qualified health care professional, and ideally it should be part of the nursing admission process.
  2. Based on this screening and based on need, was there a referral to a registered dietitian for a more detailed nutritional assessment, with recommendations? This assessment should be comprehensive and include the following: a food history and adequacy of nutrient intake; anthropometric measurements, including height, weight, and body mass index; biochemical data based on the patient's diagnosis; a nutrition-focused physical assessment (NFPA); and the patient's ability to eat independently. Serum albumin and pre-albumin, long considered to be serum markers of nutritional status, are no longer considered reliable indicators. More on this later.
  3. Is a risk assessment tool for pressure injury risk completed that includes nutrition, such as the Braden Scale for Predicting Pressure Sore Risk©? Is it accurate based on the patient's nutritional status, to include appetite, protein intake, tube feeding, total parenteral nutrition, dietary supplements, and NPO (nothing by mouth) status or IVs for more than five days?
  4. Is there an appropriate care plan with evidence-based nutrition support and interventions based on this screening and assessment?
  5. If the patient's functional feeding capacity is poor, what assistance or special measures are being enacted to optimize intake? Does the patient require extensive assistance to eat, and is this assistance indicated in the chart? Are nurses and caregivers charting measures to encourage intake of food?
  6. If the patient or family is non-compliant with the diet, is this charted? What are the reasons for this non-compliance, and what patient education has staff done?
  7. If dysphagia or swallowing and feeding difficulties are detected, has there been a speech therapy consultation to counter this condition and to optimize nutrition? What is the patient's swallowing status, and is an appropriate diet or consistency ordered?
  8. Is intake, both food and fluid, monitored and charted?
  9. Is there continued involvement of the dietitian with regular follow-up and notes?
  10. Is the patient's weight being monitored with regularity, based on the patient's food intake and weight trends? Is there a physician order for weight monitoring, and is it actually taking place and being recorded in the chart?
  11. In long-term care, do nutritional assessments and documentations match what is on the Minimum Data Set (MDS)? The Centers for Medicare & Medicaid Services define risk as loss of weight greater than 5% in 30 days or 10% in six months.
  12. In the case of people with diabetes, is blood glucose monitored as per order, reasonably controlled, and is the hemoglobin A1c being monitored, with adjustments to diet and medication as needed?
  13. Is hydration adequately provided, and are fluids encouraged as needed? Is there a hydration care plan in place, and do the nurses chart that fluids were encouraged? Are practitioners monitoring signs of dehydration such as changes in weight, skin turgor, urinary output, serum sodium, blood urea nitrogen, and creatinine levels?


These are just some of the basics to look for in your practice in an effort to provide evidence-based nutrition care for patients and hopefully survive perusal of charts in case of litigation or—better yet—to avoid litigation completely! In the next part, I will drill down a bit more in terms of nutrition assessments, the NPIAP guidelines, and other interventions.

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.