It is against this backdrop that the pressure sore case must be evaluated. Pressure sores are prevalent in nursing homes because elderly and infirmed residents are often immobile, bed bound or chair bound. A pressure sore develops because of pressure and/or friction over an area of skin, resulting in decreased blood flow to that area. Affected areas are typically the sacrum, coccyx, feet and heels. If the pressure is not relieved, the area develops into an open sore and death of tissue ensues. As the sore widens and deepens, layers of the skin can be eviscerated, exposing the bone below. Seventy percent of pressure sores occur in patients over the age of 70 and ninety-five percent of pressure sores develop on the lower body.
Pressure sores are graded or staged according to their severity. Stage I is intact skin with a nonblachable redness in a localized area, usually over a bony prominence. Stage II is a shallow open sore where the skin has been broken. Stage III is when the pressure sore has advance to the point that there is full thickness tissue loss so that the fat underlying the skin is exposed. Stage IV is when the sore is so deep that underlying bone, tendon or muscle is exposed. A pressure sore may also be “unstageable,” because the base of the ulcer is covered by slough or eschar making accurate staging of the depth difficult. Most pressure sore lawsuits involve Stage III or IV pressure sores. Pressure sores in the lower extremities can cause gangrene resulting in amputation. Open bed sores anywhere on the body can become the site of an infection and progress to sepsis, and ultimately cause the death of the patient.
Both federal and state regulations speak to the issue of pressure ulcers. Both provide that the resident has the right to be free of pressure sores which are medically preventable. Specifically, the regulations provide that the nursing home must ensure that the resident does not develop pressure sores unless they are “clinically unavoidable.” If the resident comes into the nursing home with an existing pressure sore, the facility is charged with the responsibility of providing the necessary services and treatments to promote healing, prevent infection and prevent new sores from developing.
The issue of “clinical unavoidability” is central to the prosecution and defense of the pressure sore claim. The focus is on whether the facility appropriately assessed the resident’s risk of developing a pressure sore and created a plan of care to address that risk. Often the nursing home chart demonstrates the risk was identified and a plan of care was developed. Then, the battleground shifts to the issue of whether the interventions and precautions ordered were actually implemented by the facility staff. The answers to these questions are revealed by a detailed analysis of the nursing home chart.
In addition to immobility, certain medical conditions can enhance the resident’s risk of developing pressure sores, and when they develop, make them more challenging to heal. Those conditions include urinary and fecal incontinence, peripheral vascular disease, malnutrition, diabetes, end stage renal disease, gastrointestinal disorders and malabsorption disorders, among others. Some medical conditions are believed to impede or prevent healing of pressure ulcers: metastatic cancer, cachexia, multiple organ failure, sarcopenia, severe vascular compromise and terminal illness. Resident’s rights advocates argue that the presence of risk factors put the facility on notice of the need for aggressive preventative measures. Nursing home defense counsel, on the other hand, argue that the presence of multiple risk factors make the development of the pressure sore clinically unavoidable.