Pressure Sores (Bedsores, Pressure Ulcer, Decubitus Ulcers)

Pressure Sores (Bedsores, Pressure Ulcer, Decubitus Ulcers)

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The Elderly Are Susceptible to Painful, Even Deadly Sores, Ulcers, and Infections

The elderly nursing home population is very susceptible to developing pressure ulcers, also known as bedsores, pressure sores and decubitus ulcers. Bedsores are a serious condition and can cause sepsis (blood infection), gangrene, osteomyelitis (bone infection), joint infection, MRSA (bacterial infection) or necrotizing fasciitis (flesh-eating disease) all of which can require amputation of an extremity or cause death.

Pressure ulcers are areas of tissue/skin destruction caused by pressure and friction. They usually develop over bony prominences like the heels, sacrum/lower back, back of the head, elbows and shoulder blades. The cells in the skin die when they are deprived of blood.

When blood supply is interrupted when skin is compressed between bone and an exterior surface like a bed, pillow or wheel chair for an extended period of time pressure sores can develop. For example, people that are restricted to a bed need their head elevated approximately 30 degrees to prevent aspiration (a condition where food or liquids are breathed into the lungs). However, elevating the head 30 degrees increases the pressure on the back of the head and the sacrum.

More About Pressure Sores, Skin and Tissue Infections, and Decubitus Ulcers

Nursing Home Obligations to Newly Admitted Residents

A nursing home resident is likely to develop a bedsore within the first 4 weeks of being admitted into the nursing.

Federal law requires nursing homes to develop and implement a comprehensive assessment of the resident when they are admitted, to ensure that:

  • “A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were avoidable; and”
  • “A resident who enters the facility with pressure sores receives necessary treatment to promote healing, prevent infection and prevent new sores from developing.”

So nursing homes have a duty to prevent bedsore that are preventable and they must treat existing bed sores and prevent infection, prevent new sores from developing, and allow existing sores to heal.

In order to effectively prevent pressure sores and identify a newly admitted resident with existing pressure sores the nursing home staff needs to perform a complete and thorough assessment of new nursing home residents. This assessment allows the nursing home to identify new residents that are at risk of developing bed sores or who enter with preexisting signs of bed sores.

Illustration of the four bedsore pressure ulcer stages.
Illustration of the four stages of Classification of Bedsore Pressure Ulcers. Stage I ulcers should be immediately addressed. Stage II and Stage III presents worsening symptoms until Stage IV in which deep tissues injuries may result. Healing time is prolonged for higher stage ulcers. While about 75% of Stage II ulcers heal within eight weeks, only 62% of Stage IV pressure ulcers ever heal, and only 52% heal within one year. Pressure ulcers do not regress in stage as they heal. A pressure ulcer that is becoming shallower with healing is described in terms of its original deepest depth (e.g., healing Stage II pressure ulcer).

What is a Nursing home’s obligation to a newly admitted resident who enters the facility without bed sores?

A qualified professional should complete a pressure sore risk assessment when a new resident is admitted to the nursing home. In order to gain a full understanding of the new resident’s overall health a full history and physical examination needs to be performed. The history should include a nutritional assessment to determine if the new resident is malnourished and needs to be place on a specific diet that will give the body the nutrients it needs to prevent infection and skin breakdown. This assessment should also be performed periodically after the resident has been admitted. Several bedsore risk assessment tools exist to aid nursing home staff including The Braden Scale, The Norton Scale and the Minimum Data Set 2.0 (MDS2) which must be used by facilities that accept patients on Medicare.

Generally speaking residents with some degree of immobility are a high risk of developing bed sores. Residents that are confined to beds or reliant on wheel chairs to get around require assistance with repositioning and mobility.

Urinary incontinence is known to increase skin moisture and this added moisture can breakdown skin. Fecal incontinence can result in a buildup of bacteria, bile acids and harmful enzymes that breakdown skin.

Additional risk factors include malnutrition and dehydration, a history of pressure sores, desensitized skin, peripheral vascular disease, renal disease, thyroid disease, diabetes, low circulation, use of steroid related drugs which inhibit wound healing, cognitive impairment.

The nursing home staff then needs to development and implement a pressure sore prevention program for those newly admitted residents that are at risk of developing pressure sores. Residents that are determined to be at risk of developing bed sores need an aggressive prevention plan. The prevention plan can include a turning and repositioning regime that allows skin tissue to recover from pressure, teaching a wheelchair bound resident techniques to lift their body off the seat periodically, use of pressure relieving mattresses, heel guards, monitoring of nutrition and hydration, skin car/hygiene. Lifting and turning sheets and devices can be used to prevent friction and shearing skin tear injuries during bed, wheelchair and toilet transfers.

The bedsore risk assessment is the most important element of a nursing home’s bedsore prevention program. Most of the nursing home guidelines advise performing an assessment when the resident is admitted. They also recommend weekly pressure sore risk assessments for the first 4 weeks and then quarterly risk assessments thereafter.

Most pressure sores are preventable. However, some nursing home residents are at such a high-risk of developing bed sores that nothing can be done to prevent them. However, any nursing home that fails to identify a new resident that is at risk of developing bed sores or that fails to develop and implement an appropriate prevention program for residents that are at risk of developing bed sores will be responsible for the development of future bed sores if they were preventable. They will also be responsible for any of the complications that result from the development of preventable bed sores (i.e. sepsis, gangrene, amputation, death).

What is a Nursing home’s obligation to a newly admitted resident who enters the facility with bed sores?

A qualified professional needs to properly identify and assess any bed sores that exist on a new resident when they are admitted. The pressure sore needs to be assigned the correct stage. There are four stages of pressure sores, stage 4 being the worst. In order to assign the pressure to the correct stage the nursing home professional needs to have an in-depth understanding of tissue recognition and human anatomy. However, simply identifying a bedsore’s stage is not sufficient. The clinician must identify and record several characteristics including the bedsore’s size, location, depth, presence of odor, drainage, necrosis (death of skin tissue), wound bed tissue, sinus tracts, tunneling (any holes that exist deep into the tissue) and undermining (the tissue around the wound).

A treatment plan needs to be put in place after the bedsore is assigned a stage and all its characteristics have been identified and recorded. Treatment plans should include the following elements: a periodic turning and repositioning regime to aid with mobilization and bedsore healing, use or bed/toilet/shower transfer techniques and devices to prevent shearing, use of air mattress/water-bed/, dead tissue prevents healing and should be removed through debridement procedure, management of underlying conditions like diabetes/malnutrition/dehydration, maintaining enough moisture in and around the wound to promote healing, packing wound cavities.

Most bed sores show improvement in two to four weeks. In some cases though bed sores get worse over time or simply fail to improve. Nursing homes need to monitor existing pressure sores in order to determine if they are getting better or worse. Documenting the status of the bedsore on a consistent basis allows nursing home staff to accurately determine bedsore progress and adjust treatment accordingly. Many assessment tools exist to monitor and document the status of the pressure sore. One is the PUSH tool, which classifies the pressure ulcer by length and width, tissue type and exudate amount. These three classifications are then used to assign the bedsore a rating score. A nursing home resident’s chart should show the bedsore’s rating score is improving over time. The PSST (Pressure Sore Status Tool) is another test nursing homes use to monitor the status of bed sores. This test uses 13 items to determine a rating score. Nursing homes need to know if the pressure sore is getting better because if it fails to get better within 2 to 4 weeks the Nursing home is required to reassess the resident’s pressure sore and overall condition. A lack of consistent and accurate documentation by the nursing home staff raises concerns that the nursing home is providing negligent care.

Experienced Nursing Home Pressures Sores and Bed Sores Attorneys

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