Case Study: End-of-Life Pressure Ulcer

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. She had been in the hospital at least four times in her last year, the latest involving respiratory failure with intubation twice. Her kidneys had failed, requiring hemodialysis. She endured multiple sepsis infections with multidrug-resistant Acinetobacter and vancomycin-resistant enterococci, as well as recurrent C. diff infections with continued severe diarrhea. The family refused palliative care involvement because they refused to believe that their mother was nearing end of life. Numerous practitioners in multiple facilities charted that the family was unrealistic in their expectation that she would recover. Even toward the end of the last hospitalization, the family refused to discuss hospice care. The patient eventually developed a deep and necrotic stage 4 pressure ulcer that needed surgical debridement and became the focus of a lawsuit; she died almost two years after her initial admission to the facility.

Legal Perils and Pitfalls of Wound Care
 

With her multiple comorbidities and advanced age, there can be little doubt that the development of the ulcer was part and parcel of end-of-life skin failure. But to prevail, the facility had to show that they indeed met the standards of care related to pressure ulcer care.

Defense Strategies Against Pressure Ulcer Lawsuits

Does any of this sound familiar? How would your facility stand up to legal scrutiny, and could it prevail in a lawsuit? As 90% of all cases do, this one settled out of court, but for a substantially smaller amount than plaintiff was seeking, so it was considered a victory for the defense. What had the facility done right? Fortunately, the documentation was good, detailing the multiple interventions that were instituted and addressing the many issues that plaintiff attorneys frequently target in a pressure ulcer lawsuit. The facility's defense included the following areas of care:

• Thorough assessments every time the patient was readmitted to the facility from one of her many hospitalizations. These assessments showed deterioration of the wound each time on readmission. The reason for this is clear: patients are hospitalized when they experience exacerbations of their disease, become sicker with ever-increasing risk factors, and experience deterioration of skin breakdown and pressure ulcers with each exacerbation.
• Good turning and positioning documentation, as well as other pressure reduction measures. The documentation displayed a strong emphasis on skin and pressure ulcer care. There were physician orders for turning and positioning and other prevention and treatment measures, and these were included and signed for on the Treatment Administration record.
• Consistently placing the patient on a pressure-redistribution surface and charting exactly what surface she was on as it was gradually upgraded. Often, one of the most common unknowns when I review charts is, "What surface exactly were they on?"
• Conducting skin risk assessments on admission and then on a regular basis and being consistent in risk assessments. The mobility and activity scores on the Braden scale matched what physical and occupational therapy were charting.
• Consistently using skin barrier products to protect her skin from incontinence, charting their use, and identifying which products were used. Incontinent episodes, especially diarrhea, were reported to nursing staff and documented in the chart.
• The facility had a well-educated, active, and informed wound care team who made weekly rounds that included a certified wound care nurse, a registered dietitian, the charge nurse from the unit, and therapy services.
• Pressure ulcers were assessed and charted weekly and included all the necessary elements of wound assessment. There was consistency in the assessments. The physician was kept informed about the pressure ulcer and made the effort to assess the skin issues in the facility personally.
• The family was well communicated with and kept informed of all changes in the patient's condition, including the pressure ulcer. This communication was documented in the chart, and relevant conversations or statements by the family were quoted. Additionally, the family was invited to all care plan meetings.
• Nutrition service was involved in the patient's care, assessed relevant laboratory test results and anthropometrics including her weekly weights, and made regular recommendations to optimize her nutrition.
• Any pain issues were regularly assessed, documented, and treated with prescribed pain medication and other interventions as needed.

Conclusion

We now know that not all pressure ulcers are avoidable, especially with end-of-life issues and organ failure. But we still will be held accountable for skin breakdown and pressure ulcers and be liable for lawsuits if proper care and documentation is not present. How would your facility stack up?

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.