Pressure Injuries

By Heidi Cross, MSN, RN, FNP-BC, CWON 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.

By Heidi Cross, MSN, RN, FNP-BC, CWON "At all times material hereto, defendant failed to develop an adequate care plan and properly monitor and supervise the care and treatment in order to prevent her from suffering the development and deterioration of bed sores."

by Heidi H. Cross, MSN, RN, FNP-BC, CWON "If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed sore, it is generally the fault not of the disease, but of the nursing." —Florence Nightingale Ouch! What an indictment of nursing and, by extension, the facility in which the nurse works. We have a lot to thank Florence Nightingale for—a brilliant woman considered to be the founder of nursing and nursing standards and the first to ever put statistics to health care, among other valuable contributions.

As detailed in my last few blogs, nutrition plays a huge role in risk for skin breakdown as well as healing of wounds. Just about ALL wound litigation involves nutrition in one way or another, be it diabetes control (or lack thereof) or weight loss, which occurs often in patients with dementia and toward end of life, or general malnutrition.

By Heidi Cross, MSN, RN, FNP-BC, CWON Since the advent of coronavirus disease 2019 (COVID-19), I haven’t done much flying, but I love travel and I love flying. One of my favorite experiences is a window seat at about 30,000 feet on a clear sunny day. The views can be spectacular – whether flying across the Rockies or the Plains or any of the stunning and varied scenery of this country or the world. A couple of my most memorable flights involved flying into New York City with views of the New York skyline with Lady Liberty in clear sight, or into Washington, DC with clear views of the Mall, the Jefferson Monument, and the Capitol. The Alps and the Rockies are incredibly awe-inspiring, beautiful, and breathtaking. From there, you get a good overall picture of the landscape.

by Heidi H. Cross, MSN, RN, FNP-BC, CWON Failure to T&P (turn and position) is always part and parcel of a pressure ulcer lawsuit and a key element of a complaint related to pressure ulcers, as illustrated in the opening quotation. T&P documentation is a dominant focus in chart analysis and is usually one of the first things that an attorney and the expert witness look for. If T&P documentation is satisfactory, the defendant is likely to prevail; if not, then the plaintiff may have a pretty rock-solid case. But as I have opined in previous blogs, is there such a thing as perfect documentation? Alas...NO! (Or at least, rarely.)

by Heidi H. Cross, MSN, RN, FNP-BC, CWON When looking at medical charts from a legal perspective, one of the areas closely scrutinized is the risk assessment for skin breakdown and pressure ulcer development. Completing a risk assessment is considered a standard of care. Was the patient adequately assessed, and was this done in a timely fashion? Was it repeated at regular intervals, with a change in condition, or on readmission? Do scores seem appropriate for the patient's condition? Is there consistency among health practitioners? Were the results used to institute evidence-based and appropriate prevention and treatment measures and care plans? Or do the results seem to simply languish in the chart? What are the standards of care related to this?

By Heidi Cross, MSN, RN, FNP-BC, CWON "It was the best of times, it was the worst of times." – Charles Dicken When Charles Dickens wrote this introduction to his Victorian-era novel, A Tale of Two Cities, his novel was aimed at the brewing French Revolution, but he could have been writing about the best and worst of modern American health care. His novels depicted how life could be pretty miserable during those times, with no social safety net and no real medical care. Fortunately, times have changed, and we have improved social supports as well as, some would argue, the best health care system in the world (although, sadly, not all people in the United States enjoy access to our great health care system, but I digress).

In the previous blog, I briefly went through the standards of care when it comes to nutrition and pressure injury (PI) prevention and development and discussed what a large role nutrition plays in PI litigation. Here are several instances: Punitive damages of $92 million, later lowered to $11,855,000, were imposed where malnutrition and dehydration were proven against a nursing home. A dietary manager for a nursing home told state surveyors that her nursing home had "dropped the ball" on a resident's nutrition needs when that resident had lost 17 pounds in 75 days; a $1,385,000 settlement was reached. Malnutrition with a loss of 27% of body weight in 15 months led to a $380,000 settlement just before trial. Shocking, isn't it? It literally "pays" to pay attention to nutrition standards of care.

By Heidi Cross, MSN, RN, FNP-BC, CWON "Defendants failed to provide adequate nutrition to prevent plaintiff from suffering severe malnutrition and weight loss. This allowed the development of a severe pressure ulcer, numerous infections, and dehydration and malnutrition. Had defendants provided proper care, the pressure ulcer, infections, and malnutrition and dehydration would not have occurred."