According to the Agency for Healthcare Research and Quality,1 more than 17,000 lawsuits related to pressure ulcers are filed annually in the United States, second only to wrongful death lawsuits. One of the greatest gifts to defense attorneys was when the Centers for Medicare & Medicaid Services (CMS) published F-Tag 314, finally acknowledging that some ulcers can occur despite best care. The facility essentially can maintain, "Hey, we did everything we were supposed to, and despite that, the patient developed that pressure ulcer"—that is, the ulcer was unavoidable. To prove unavoidability, proper documentation (proof) of best care needs to be in place, as well as documentation that all proper prevention and treatment measures were implemented.
Intrinsic risk factors include skin failure, which often (but not always) is associated with end of life. Skin failure has been defined as "an event in which the skin and underlying tissues die due to hypoperfusion that occurs with severe dysfunction or failure of one or more organ systems."2 As we know, skin is an organ just like the heart, kidney, and liver, and it is the largest organ of the body. Unless there is actual medical malpractice, how often do we hear about patients suing cardiologists for heart failure, nephrologists for kidney failure, and hepatologists for liver failure? Granted, we have serum laboratory values for failures of the heart (B-type [or brain] natriuretic peptide), kidney (blood urea nitrogen, serum creatinine), and liver (liver enzymes); however, none exist for skin failure.
But why so many lawsuits for pressure ulcers, when organ failure (as in other organs) may be the causative issue? Why do families and patients get upset enough with pressure ulcers that they feel compelled to sue? In addition to being the largest organ, skin is outwardly visible, and skin breakdown can be shocking and jolting to patient family members, unlike the invisibility of many other organs. It can easily be interpreted as a sign of abuse and neglect and has become the low hanging fruit of lawsuits and the bread and butter of many medical malpractice plaintiff attorneys. Just look at some of the ads.
Many experts and expert bodies have weighed in on this issue, and some of these were detailed in my last blog. I would like to focus on the consensus panel article of the National Pressure Ulcer Advisory Panel (NPUAP), published in 2014.3 This article divides the risk factors into intrinsic and extrinsic factors. Please see this article for a more complete version. I will discuss extrinsic risk factors in the next blog.
Not all pressure ulcers are avoidable, despite best care practices. Contributors to unavoidability include intrinsic risk factors, skin failure among them. Next blog? Extrinsic risk factors for unavoidable ulcers according to the NPUAP.
1. Agency for Healthcare Research and Quality. www.ahrq.gov. Accessed April 6, 2019.
2. Langemo D, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19(4):206–11.
3. Edsburg LE, Langemo D, Baharestani MM, Posthauer ME, Goldberg M. Unavoidable pressure injury: state of the science and consensus outcomes. J Wound Ostomy Continence Nurs. 2014;41(4):313–34.
4. Consortium for Spinal Cord Medicine. Early acute management in adults with spinal cord injury. A clinical practice guideline for health care professionals. J Spinal Cord Med. 2008;31:408–79.
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.