Nursing Home Negligence

Placing a family member or loved one in a nursing home or assisted living facility is a very difficult decision.  Nursing home residents typically require assistance with many activities of daily living and require careful monitoring and attention by the facility’s staff.  These vulnerable nursing home residents are at risk for serious injury if they do not receive proper and adequate care.  For instance, nursing home residents may suffer serious life-threatening injuries resulting from bedsores (also known as pressure uclers or decubitus ulcers), falls, dehydration/malnutrition, urinary tract infections, medication errors or failures to monitor the resident.

Most physicians would agree that the minimal standards of care applicable to such nursing homes facilities is:

  1. to ensure that a resident entering the facility without pressure ulcers does not develop them unless the resident’s clinical condition demonstrates that they were medically unavoidable;
  2. to prevent the resident from experiencing falls, including but not limited to the development and implementation of fall prevention mechanisms;
  3. to develop, document, implement and monitor the efficacy of a comprehensive care plan to achieve the highest practical physical, mental and psychosocial well-being consistent with the resident’s condition and advance directives and revise the care plan as needed;
  4. to perform a comprehensive assessment of the resident’s physical, mental, and psychosocial needs on initial admission and any subsequent admissions;
  5. to maintain an accurate and complete clinical record that reflects (a) the care and treatment provided to the resident; (b) the resident’s current condition and any changes in the clinical condition; (c) any responses to interventions; and (d) a record of communication between the physician and the facility staff regarding the resident’s condition and care and treatment plan;
  6. to promptly and thoroughly assess all changes in the resident’s physical, mental and psychosocial condition, and communicate such changes to the attending physician;
  7. to implement any care and treatment ordered by the attending physician;
  8. to ensure that all significant, non-emergent changes in the resident’s physical, mental and psychosocial condition are promptly communicated to the physician;
  9. to maintain an accurate and complete clinical record that reflects (a) the care and treatment provided to the resident; (b) the resident’s current condition and any changes in the clinical condition; (c) any responses to interventions; and (d) a record of communication between the physician and the facility staff regarding the resident’s condition and care and treatment plan;
  10. to follow up and report diagnostic study reports to the attending physician in a timely manner.

Patients residing at nursing homes are often at risk of developing pressure sores/decubitus ulcers as a result of their underlying health problems and immobility issues.  A pressure sore/decubitis ulcer is a bedsore that comes from lying in the same position too long and is associated with pain. 

Nursing home patients experience pressure from the bed and/or chair to certain points on their skin preventing the blood from flowing into those points.  Because the blood is not allowed to flow into those points, the skin, deprived of nutrients and oxygen, can become injured and susceptible to infection.

Pressure is a primary contributing factor to the development of pressure ulcers.  Since the development of pressure ulcers depends on the length of time pressure is applied, immobility is the major risk factor.  Pressure must be relieved.  Malnutrition and adequate hydration have been linked to the development of pressure ulcers. 

A stage one ulcer presents as redness of the skin and represents tissue injury and heralds skin ulceration.  A stage one ulcer is classified as nonblanchable erythema with intact skin.  Erythema is redness of the skin produced by congestion of the capillaries.  Erythema is the initial reactive hyperemia caused by pressure, and nonblanchable erythemia represents s stage one pressure ulcer.

A stage two ulcer is characterized by partial-thickness skin loss, that is, the epidermis is interrupted as an abrasion, blister or shallow crater.

A stage three ulcer features full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend to, but not through, the underlying fascia.  The ulcer appears as a crater, with or without undermining of adjacent tissue.

A stage four ulcer involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., a tendon or a joint capsule).

With stage 3 or 4 pressure ulcers, the extent of the disease may not be evident because of covering necrotic material or eschar.  To establish the extent of the disease and promote healing, the necrotic material needs to be removed and surgical consultation may be required.  When ulcers develop over bony prominences, osteomyelitis is a potential complication.  Pressure ulcers are chronically contaminated wounds and the combination of bacteremia and pressure sores can be painful and life threatening.

Ultimately, pressure ulcers are avoidable so long as proper care and preventative measures are instituted and implemented by the nursing home.  In fact, under new Medicare guidelines, hospitals are no longer reimbursed for additional care resulting from bed sores and several other “reasonably preventable” errors including objects left in the body after surgery. The government has determined that development of bedsores at a hospital is a so-called “never event.”

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