Introduction

In medical malpractice litigation, a thorough review of the medical chart is done to determine whether the facility or health care provider “met the standards of care” related to the medical issues at hand in the complaint. Attorneys hire specialists in the field to serve as expert witnesses to make this determination. Whether the case is settled or goes to trial, if the facility can show that it met most if not all standards of care, then the defense prevails. If not, the plaintiff has proved neglect with a breach of duty and receives compensation.

Definition of “Standards of Care”

Medical standard of care is typically defined as the level and type of care that a reasonably competent and skilled health care professional or facility, with a similar background and in a similar medical community, would have provided in a similar situation and given the same resources. Rising above the standard with expectations of “perfect care” is not a reasonable expectation and does not have to be proved to prevail in litigation. What constitutes the standards of care will change from community to community and often evolves over time.

How Standards of Care are Determined

Standards of care are generally not explicitly written down. They are determined by the analysis, opinions, and testimony of expert witnesses who have the knowledge and similar experience as the practitioners or facilities involved. In the case of pressure injury prevention and treatment, as well as nutrition, they will be practitioners (physicians, nurses, other health care providers) with wound care experience and perhaps certification, in addition to registered dietitians. Standards are usually based on clinical practice guidelines that are research based and peer reviewed, and most experts term them “best practices.” Examples of these are guidelines from The National Pressure Injury Advisory Panel (NPIAP), the Wound, Ostomy and Continence Nurses Society, the World Union Wound Healing Societies, and the Academy of Nutrition and Dietetics, among others.

Wound Care Standards of Care

Here are some questions clinicians can ask themselves to help determine whether their facility is meeting standards of care related to wound care. Many of these questions are based on the NPAIP 2019 pressure injury guidelines,¹ among others:

1. Was a skin risk assessment performed on admission and then regularly to determine risk of skin breakdown?
2. Was an appropriate care plan devised based on that assessment incorporating bedside clinical judgment? Is the patient or family involved and aware of the care plan?
3. Was the medical provider as well as the family notified about the skin breakdown and then kept abreast of any changes?
4. Were appropriate skin and wound assessments performed, including all parameters as suggested in guidelines?
5. Were appropriate turning and positioning measures documented as performed?
6. Were the care plan and wound treatments revised as needed based on change of condition, improvements, or deterioration?
7. Was nutrition screening performed on admission, by using a valid and reliable nutrition screening tool? This screening can be done by any qualified health care professional, and ideally it should be part of the nursing admission process.
8. Based on this screening and based on nutrition status, was there a referral to a registered dietitian for a more detailed nutrition assessment with recommendations?
9. Were these nutritional recommendations implemented and documented as performed?
10. If the patient’s functional feeding capacity is poor, what assistance or special measures are being enacted to optimize intake? In addition, is hydration status assessed, and are fluids encouraged as needed?
11. Was the patient placed on appropriate support surfaces, for bed and chair, to redistribute pressure?
12. If the patient refuses or is nonadherent to suggested interventions, is this documented? What education is taking place in an effort to obtain adherence to the plan? Are continued refusals redocumented?
13. What efforts are made to optimize mobility, such as physical therapy, occupational therapy, and restorative nursing?
14. If dysphagia or swallowing and feeding difficulties are detected, has there been a speech therapy consultation to counter this condition and to optimize nutrition? What is the patient’s swallowing status, and is an appropriate diet and consistency ordered?
15. Is intake, both food and fluid, monitored and charted?
16. Is there continued involvement of the dietitian with regular follow-up and notes?
17. Is the patient’s weight being monitored with regularity, based on the patient’s food intake, health status, and weight trends? Is there a physician order for weight monitoring, and is it actually taking place and being recorded in the chart?
18. In the case of patients with diabetes, is blood glucose monitored as per order, reasonably controlled, and is the hemoglobin A1c being monitored, with adjustments to diet and medication as needed?
19. Is pain assessed and treated, always including location of pain so that it is not falsely attributed to the ulcer if the pain is musculoskeletal or has other causes?
20. Is continence assessed, is an appropriate care plan developed, and is treatment implemented?

Conclusion

This discussion represents a brief synopsis of the questions you need to consider. The “standard of care” is a legal concept and not necessarily a medical concept. A clinician’s effort to meet standards or lack thereof will largely determine medical malpractice outcomes. It is important to be aware of the standards related to pressure injury prevention and treatment as well as nutrition, hopefully to survive perusal of charts in case of litigation or—better yet—to avoid litigation completely.

Key Takeaways

In medical malpractice lawsuits, plaintiff attorneys want to show how a health care provider or facility violated the accepted standards of care and was therefore negligent. Clinicians should protect themselves through awareness of the standards and ensure that these standards are incorporated into their individual practices, as well as their facility’s practices.

Reference

1. National Pressure Injury Advisory Panel. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline 2019. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance 2019.

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.