Case Study: Patient’s Health Deteriorates Due to Improper Pressure Injury Care
Case Details
The patient was a male in his mid-eighties who had a history of prostate and bladder cancer leading to bone metastasis. Following a hospital stay, he was transferred to a long-term care/rehabilitation (LTC/rehab) facility. When the patient arrived at the facility, the admissions nurse documented that he had a Stage 4 sacral pressure injury.
The patient subsequently developed several Stage 2 and Stage 3 pressure injuries on the buttocks. Nurses at the facility did not complete daily skin assessments and never documented any wound assessment or patient response to wound treatment. Within 2 weeks, the patient developed a C. difficile infection, and the sacral pressure injury progressed to involve the patient’s bone.
Wound VAC therapy was ordered, but didn’t occur immediately. The patient eventually was admitted to the hospital, and his condition continued to worsen. He developed sepsis and pneumonia, and ultimately did not survive.
Discussion
The major risk management issues in this case revolved around the failure of LTC/rehab staff to follow proper care protocols, adequately monitor the patient, and document care.
The patient’s Stage 4 pressure injury was documented at admission; 1 day after his admission, a nurse documented redness in the patient’s groin area. However, after that, no further information was documented related to the groin or perineal area.
Additionally, the nursing staff failed to follow the facility’s protocol for daily skin assessments. Although staff did document wound treatment and dressing changes, they did not document wound assessment or response to treatment. Documentation does show that one of the patient’s pressure injuries healed, but the sacral pressure injury continued to deteriorate while the patient was at the facility, and other wounds developed as well.
About 4 weeks after the patient was admitted to the LTC/rehab facility — and after he developed the C. difficile infection — an attending physician ordered wound VAC therapy. The therapy was not started until a week later, but documentation was insufficient to show why the delay in treatment occurred. During the patient’s wound VAC treatment, no follow-up assessments were done, which was in direct conflict with the facility’s policy of weekly wound evaluations. Further, excoriated skin in the groin/perineal region was not addressed in the patient’s care plan.
Following the patient’s death, his family filed a malpractice suit against the LTC/rehab facility citing failure to monitor the patient’s physiological status. The case was settled with a payment made on behalf of the facility.
In Summary
Pressure injuries are a common, yet serious problem in LTC, rehab, and nursing home facilities. MedPro claims data show that allegations involving pressure injuries occur in 27 percent of cases associated with skilled nursing facilities and 7 percent of cases associated with assisted living facilities.[i] Without appropriate care and treatment, pressure injuries can result in pain, infections, disfigurement, hospitalizations, and increased risk of death.
Preventing pressure injuries requires an interdisciplinary approach to care. Although some parts of the approach are very standardized, providers also must tailor care to each patient’s specific risks. Pressure injury prevention requires coordination among many individuals, including the multiple disciplines and teams involved in developing and implementing the care plan.
To learn more about preventing pressure injuries, see MedPro’s Checklist: Preventing Pressure Injuries in Senior Care Organizations, the Agency for Healthcare Research and Quality’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention, and the National Pressure Injury Advisory Panel website.
Endnote
[i] MedPro Group. (2024). Senior care: A coded case analysis. Retrieved from www.medpro.com/documents/10502/5086245/Senior+Care_Claims+Data+Analysis_2024_MedPro+Group.pdf
Disclaimer
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