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Pressure Ulcers: Changing habits can combat clinical and legal problems

July 5, 2012
by Karl Steinberg, MD, CMD
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Despite improvements in technology and an ever-increasing array of dressings and topical agents, pressure ulcers and other wounds are still a common problem in skilled nursing facilities. Many costs are associated with wounds, including the direct economic expenses of treatment, the personal cost of pain, the disability and indignity, and the liability-related costs to healthcare providers. For acute-care hospitals, hospital-acquired Stage III and IV pressure ulcers are now considered by the Centers for Medicare & Medicaid Services (CMS) among the “never events” that negatively impact compensation. There has been talk of expanding “never events” to skilled nursing facilities, but so far that has not occurred. The federal guidelines and the guidance to surveyors recognize that not all pressure ulcers are avoidable in the long-term care setting (see Long-Term Living, November 2009). But the fact that some wounds are unavoidable does not keep residents and their families from being upset and blaming facilities, and does not keep plaintiffs’ attorneys from bringing successful lawsuits against long-term care facilities.  

For those who see pressure ulcers and other wounds on a daily basis, they are seldom impressive or shocking. But to a lay person like a resident’s family member (or a juror, for that matter), even a photo of a shallow stage II ulcer with great, beefy-red granulation tissue can provoke a dramatic and visceral reaction. Some attorneys may take advantage of charting inconsistencies and suggest that the development of pressure ulcers is de facto evidence of substandard nursing attention, painting a picture of deliberate understaffing and corporate schemes to place profits above patient care. Small wonder that juries want to “send a message” that such practices are unacceptable.   


Clearly, there are instances where poor care does indeed cause (or contribute to) the development of pressure ulcers. But often, even when good care has been provided, it is difficult for a facility to use charting documentation to demonstrate that all reasonable and appropriate measures for pressure ulcer risk assessment and prevention have been implemented. For example, there is no requirement to document each time a resident is turned and repositioned. Some nursing narrative notes will mention turning and repositioning every two hours, while others will not. Regardless of whether turning and repositioning is actually occurring, we can all agree that this type of inconsistency in charting raises significant questions as to the consistency of the actual care that is being given. Facilities tend to defend this kind of charting irregularity on the basis of “charting by exception,” where a note is made only when a routine action does not take place. This type of claim tends to ring false, especially when there is a bad outcome like a severe pressure ulcer. Add to that the observations of family members (“We were there for six hours and not once did a nurse or aide come in to check on her or turn her”), and things look very bad indeed for the facility.


So, what kinds of things can be done to reduce both the development of pressure ulcers and the liability exposure when they do develop? As an AMDA—Dedicated to Long Term Care Certified Medical Director (CMD), I may be biased; but I think having an active, knowledgeable, engaged medical director can help a lot.

Facilities should have internal guidelines for risk assessment and treatment for pressure ulcers. The guidelines should not be overly prescriptive, and they should mirror accepted guidelines such as those from the National Pressure Ulcer Advisory Panel (NPUAP) and other organizations. Be sure the guidelines reflect the most recent updates in the MDS 3.0, including recognition of (suspected) deep tissue injury (DTI) and the “unstageable” category that is used when eschar or slough does not permit visualization of the wound base.

Another trend that is gaining traction nationwide is for facilities to bring in outside wound consultants, usually physicians, physician assistants or advanced practice nurses, who can provide on-site consultation as well as debridement and other treatments when the residents’ own attending clinicians are not able to provide them. This can be a good strategy to demonstrate due diligence. Caution is advised, however. Overuse of outside wound consultants may trigger scrutiny from regulatory agencies, since there is little reason to seek an outside opinion on an uncomplicated Stage I or Stage II pressure ulcer.


Use of pressure-reducing surfaces can be helpful, although research studies have not been impressive. Foam or air mattresses are probably better than traditional mattresses, and many facilities have adopted these alternative surfaces. While higher-level pressure reduction such as alternating pressure pads or low air-loss mattresses may not be covered by insurers unless Stage III or IV ulcers are present, it may still behoove a facility to initiate these devices. It indicates good faith, and it demonstrates that the facility is serious enough about pressure ulcer prevention to choose to exceed the standard of care in this regard.