Years ago, I was working with a wound care expert witness on a case about a patient who developed terrible pressure sores or wounds after he received poor care at a hospital and then a nursing home. As a Texas medical malpractice attorney, every time I meet with a new client or family about a medical malpractice case involving pressure sores, I think of what that expert told me. He said, “The best way to treat pressure sores is to avoid them in the first place.
Any time that a patient is immobilized in bed for extended periods of time, there is a risk of developing pressure sores or bedsores, which are also called decubitus ulcers. At-risk patient may be elderly with chronic conditions, younger patients recovering from a surgery, or patients of any age that have to stay in bed for a variety of reasons.
What is surprising to many people is how quickly they develop. Research has shown that the damage to tissue under the skin at bony prominences can occur in the first hour and up to four to six hours after pressure loading. This alone highlights why proper physician and nursing care is so important from the start.
Different types of pressure sores
The National Pressure Ulcer Advisory Panel has defined different stages of pressure wounds, as follows:
Stage I Pressure Injury: Non-blanchable erythema of intact skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
Stage II Pressure Injury: Partial thickness skin loss with exposed dermis. Wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum filled blister. Adipose and deeper tissues are not visible.
Stage III Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed.
Stage IV Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.
Nursing care
The standard of care requires the nursing staff to be vigilant, when it comes to staying ahead of skin issues. Hospitals and facilities are required to have in place a standard wound prevention protocol, like the proper Braden Scale, and then to train their nursing staff on how to use it.
The idea is that a standardized assessment and documentation system allows the different shifts of nurses and doctors to track and treat any pressure injuries from the very early stages. The standard of care requires nurses to follow wound prevention protocol guidelines to perform and document a thorough skin check at least once per shift, and to keep the skin dry and clean.
Unfortunately, as a medical malpractice lawyer, I have many instances when a hospital, nursing home, or rehabilitation facility’s nursing staff has a spotty, hit-and-miss track record of using and documenting the wound prevention for evaluating patients’ potential for pressure sores.
Nurses are also required to implement prevention measures to prevent pressure wounds in immobilized patients. This includes things like placing pillows under sharp bony of the body and protecting heels. It also includes regularly repositioning the patient and, in many instances, advocating for a special bed, like an alternating pressure mattress, to help preserve healthy skin.
Physician care and mid-level providers
Bedridden or immobilized patients are cared for by a variety of providers, including surgeons, hospitalists (hospital medicine doctors), physical medicine doctors, wound care doctors, and advance practice nurses or physician assistants. All of these health care providers have a responsibility to address skin issues in their patients.
The standard of care requires these doctors and mid-level providers to conduct their own comprehensive skin assessments every time that they see an at-risk patient, and to write a note about the assessment and plan in the medical record. This a process of ongoing assessment, reassessment, and care planning to prevent, detect, and manage pressure ulcers and treatable predisposing factors such as nutrition and hydration. The comprehensive skin examination and documentation must include, at a minimum, temperature, turgor, moisture, integrity, color, and notation of the source of the alteration.
After doing these regular assessments, these providers need to write orders to make sure that the nursing staff is providing proper pressure relief and ambulation (getting the patient out of bed and moving around).
In addition, the standard of care requires the doctors and mid-level providers to assess and form a nutrition plan for any patient with compromised skin integrity or pressure wounds. The nutritional requirements to heal a pressure sore are unbelievable to most people, and without proper hydration and nutrition, the body will never have the raw materials to heal the pressure wound.
Patients who are assessed with deficits in nutritional intake and hydration may have muscle mass loss and weight loss, making their bones more prominent and making it hard for these patients to be mobile. Often with nutrition deficits and fluid imbalance there may be edema and reduced blood flow to the skin, causing ischemic damage (lack of oxygen), which contributes to skin breakdown.
Typically a nutrition plan will include orders to meet the patient’s basal requirement, plus 1.2 times the basal requirement for the activity requirement, plus 1.5 times the basal requirement when an infected bedsore is present. In terms of hydration, the standard of care requires 30 cc of fluid per kg of body weight.
What you can do
If you or a loved one is stuck in a bed in a hospital or facility, keep a close eye on skin issues. You may need to advocate yourself to get the necessary care. Wound prevention and treatment is an area that requires constant, careful attention.
Point out to the doctors and nurses any skin issues, to make sure that you get the care necessary to keep the skin clean and dry, pressure relief, and treatment for any pressure sores.
The medical malpractice lawyers at Painter Law Firm are experienced in handling bedsore cases and pressure wound cases. For a free evaluation of your potential case, call 281-580-8800.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He has extensive experience in investigating and filing lawsuits for negligence and wrongful death claims for patients and their families, based on all kinds of poor medical care, including development of bedsores, surgical and anesthesia mistakes, birth injuries, and brain injuries.
