Typical interventions to prevent the development of a pressure sore for an at risk resident include routine turning and positioning to off load pressure points, maintaining adequate nutrition and hydration, employing pressure relief devices such as a pressure relief mattress or pads or heel protectors, and providing appropriate skin cleaning and skin care. Many of these interventions are provided by the certified nurse assistants, who work under the supervision of the facility nurses. The facility should maintain some form of a CNA accountability record which documents on each shift whether the interventions required by the Plan of Care are actually being performed. Pressure sore litigation is often waged in and around the CNA accountability record. Large gaps in documenting daily care, such as the turning and positioning of the immobile resident, provide plaintiffs’ experts with a ready explanation as to why the pressure sore developed or failed to heal. Conversely, a well -documented chart of daily interventions support the facility’s argument of “clinical unavoidability.”
Sometimes the nursing home chart has missing parts, or worse, material alterations between the chart obtained before the litigation and the chart produced during the litigation. On an alarming number of occasions we have discovered fabrications in the notes, including the addition of turning and positioning entries which were not recorded in the earlier version of the chart, and even the administration of medications to a resident a day after his death.
The most damning pieces of evidence in the pressure ulcer case are the photographs of the ulcers themselves. Graphic photographs of the deep sores exposing, for example, the vertebrae in the sacrum are a compelling adjunct to the resident’s family’s testimony concerning pain and suffering. In every pressure sore case the family should be instructed to take multiple photographs of the ulcer, or a professional photographer should be dispatched to the hospital or facility for that purpose. If the resident has died, funeral directors will often permit a photographer to document the sores while the body is being prepared. Unfortunately, autopsies are rarely performed on elderly residents who expire in the hospital or nursing home from presumed natural causes. The nursing home and hospital charts should be scoured for any evidence that the facility took photographs to document wound care progression, and careful note should be made of any differences in the description of the pressure sore between the nursing home and the subsequent treating hospital. Once a pressure ulcer is identified, it should be measured by location, size and depth. It is not unusual to discover that a pressure sore is described by the nursing home staff as a Stage III on the day the resident is transferred to the hospital for definitive care, and a few hours later described as a Stage IV by the hospital emergency room personnel.
As the preamble to the New York regulations reminds us, the infirmed elderly are among the most vulnerable in the population. A large percentage of that population is at risk for developing pressure sores. Unless clinically unavoidable, pressure sores should not occur in a skilled nursing facility. Litigation of bed sore cases is one method of promoting enforcement of existing standards of care and improving quality of care throughout the industry. The practitioner would be well advised to seriously consider obtaining the nursing home chart when the family complains that a loved one has developed serious bed sores in the nursing home.