Pressure Ulcers: Changing habits can combat clinical and legal problems

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.

As far as turning and repositioning, the more consistent the documentation, the better. It should be noted that research studies on the optimal interval for turning and repositioning are also equivocal, but it makes sense empirically that the more often a pressure area is offloaded, the less likely the skin overlying it will break down. Similarly, if someone is developing skin breakdown in spite of being turned every two hours, it makes sense to turn the resident even more frequently.

With the advent of more electronic health records, we may start to see more actual documentation of each turn, which will help a great deal.

If residents refuse to be turned, or if they self-reposition back to their position of comfort, definitely document it, every time it is observed. It may be wise to get the resident a special mattress immediately; at this point, you are on notice that their risk for skin breakdown is even higher, and you need to take heightened action. Don’t let your residents sit for prolonged periods. Float heels and use heel protection devices when appropriate. These are such simple interventions, and heel pressure areas so predictable (especially after hip fracture surgery) that it seems inexcusable to let heel ulcers develop. Residents who continually draw their heels up with shear along the sheets may be a more challenging problem, but there are a variety of boots and splints that can keep the skin of the heel off the mattress.


One of the most important things we can do is to help our residents and their families develop realistic expectations. It is well accepted that the skin, like other organs, does begin to fail when death is approaching. In residents who have failure to thrive or other terminal diagnoses, it is very helpful to educate them and their families as to what the future may hold as the resident’s life draws to a close. Their nutrition, hydration and other parameters will decline. Their skin may well break down even with good care. The pain of pressure ulcers can be managed.

Empowering nursing home staff to discuss these issues can go a long way toward helping people process these difficult issues, and be prepared for what is coming. Physicians and other clinicians also need to be willing to take the time to talk about death. Having access to palliative care consultants can help reinforce the knowledge and be sure that our residents’ wishes are respected. Explaining in advance that skin breakdown is often a consequence of the dying process, not a cause of it may help to prepare residents and their families. A prepared, educated family will be less likely to be upset about skin conditions and less likely to sue the healthcare providers. Even though the conversations can be difficult and time-consuming, the education, counseling and care can benefit everyone involved.

Karl Steinberg, MD, CMD, is a full-time SNFologist (long-term care geriatrician) at Scripps in San Diego County. He is medical director for two skilled nursing facilities. He chaired the recent revision of AMDA’s Clinical Practice Guideline on pain in the long-term care setting and has served as a past president of the California Association of Long Term Care Medicine (CALTCM).

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