from Newsletter - March 2010
The skin is the largest organ of the body. Yes, organ, alive, profused with circulation, first defense, it is where you end and the outside world begins.
A pressure ulcer is the breakdown in the skin’s integrity from the inside out. We discover the pressure ulcer from the outside in, but what makes it so dangerous is that the damage starts as pressure from the bony prominences of the body pushes on the soft tissues. This impedes proper circulation and damages soft tissue cells and surrounding vessels. The breakdown process can become so severe that tissue death, muscle and bone involvement can occur.
Risk Factors
The skin and its underlying tissues depend on the proper functioning of other body organs. So, if the pancreas is inefficient, causing diabetes, diabetes becomes a risk of proper skin and soft tissue healing. The same is true for kidney, heart, and bleeding disorders; these conditions can increase the risk of pressure ulcers. Next, we add immobility, a pressure ulcer’s best ally. In the elderly profile, malnutrition, dementia, incontinence, and moisture, also increase the risk of pressure ulcers. The most at risk population for pressure ulcers is the elderly and spinal cord injured patients[i]
The potential for severe pain, suffering and calorie loss from pressure ulcers can cause a downward spiral and even death.
The Stages of a Pressure Ulcer
When a litigator is looking at the medical record describing the pressure ulcer, it is imperative that she understands the terminology of staging the pressure ulcer:
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Stage I Intact, red skin, epidermal layer damage
Stage II Partial thickness skin loss, involves the epidermis,dermis and may present
with an abrasion or blister
Stage III Full thickness skin loss
Stage IV Necrosis (death) of muscle, bone, and supporting
structures (full thickness tissue loss)
Suspected Deep Tissue Injury intact skin that is mushy or firm, maybe blood-filled, may look like a bruise yet it is a deep ulcer
Un-stage able cannot yet be staged because of the amount of grotesque dead tissue occluding depth measurement
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Location, Location, Location
The location of the ulcer is also an important clue to a litigator. The body is our most valuable real estate. What does it mean when a pressure ulcer is located on the tail bone verses the wrist?
Whether a person is thin or overweight, prolonged time left lying on one’s back can put enough pressure on the bony prominence of the sacrum (tail bone) to cause a pressure ulcer. A pressure ulcer on the wrist, heels, elbows, shoulder blades, or top of head depicts an uglier, lengthier, picture of immobility and neglect.
Albeit that an immobile person is turned and repositioned every 2 hours, you may unfortunately still see the beginnings of pressure ulcers on the sacrum or the hip bones (side lying). These are the hardest to avoid boney prominences. Again to recap, Pressure ulcers on the wrists, shoulder blades, elbows, top of the head, and heels are inexcusable.
The Standard in Nursing Care
An immobile bed bound person should be turned and repositioned every 2 hours. Pillows, foam wedges, and soft rolls should be used to relieve weight and pressure upon the bony prominences, and to maintain proper body alignment. Nursing should keep patients dry, avoid moving patients using any shearing movements, and make continuous nutrition assessments. A chair bound patient must be turned and repositioned every hour and reminded to shift their weight every 15 minutes. The entire skin surface should be assessed every day and a skin assessment tool (Braden or Norton Scores) should be used to document the skin.
Present on Admission
Understanding a potential elder abuse claim often takes the litigator to the hospital chart, although the defendant in question may be the retirement home/skilled nursing facility. Unfortunately elder neglect and abuse frequently becomes clear when the elder person is transferred to an acute hospital setting for advanced signs. One of these signs maybe a pressure ulcer or a medical condition which necessitated hospital transfer then reveals the pressure ulcer.
Initiated on October 1, 2007, hospitals have adopted the “Present On Admission” documentation standard. This standard, set out by the CDC is used in addition to ICD-9-CM Official Guidelines for Coding and Reporting to illustrate Present on Admission (POA) patient conditions for each diagnosis and external injury cause.[ii] POA provider reporting is a reimbursement incentive tool for the hospital.
For litigators deciphering negligent treatment of elderly resulting in pressure ulcers, this documentation requirement will help to clarify retirement home neglect. Not only are providers required to illustrate a clear picture of pre-existing conditions upon hospital admission, but in the case of pressure ulcers, physicians must Stage the ulcer (I-IV) as well.
Medical Documents to Behold
1. Braden or Norton Skin Assessment Scoring
2. Skin Risk Assessment Intake Sheet
3. Nursing and Physician ER Assessment Form
4. In-Patient Nursing Initial and Physician Initial Assessment
5. Physician Progress Notes
6. Nursing Notes
7. Wound Care Nurse Specialist Notes and Forms
8. Admission Orders (physician)
9. Nursing Care Plan
10. Any Present on Admission provider (physician) notations
[i] Defloor T, Schoonhoven L, Fletcher J, et al. Statement of the European Pressure Ulcer Advisory Panel—Pressure ulcer classification. J WOCN. 2005; 32:302-306.
[ii] Center for Disease Conrol, ICD-9-CM, Official Guidelines for Coding and Reporting. October 9, 2009, p. 100.
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