When Are Pressure Ulcers Unavoidable?
Are all pressure ulcers in nursing homes preventable, or are some truly unavoidable? Families often hear “it couldn’t be helped,” but understanding when a bedsore could have been prevented is key to protecting residents. These wounds can lead to serious infections and suffering if not properly managed. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Ms. Heidi Cross to talk about when pressure ulcers are truly unavoidable and what nursing homes should do to prevent them whenever possible.
Cross:
Even with clinical conditions, we still need to do everything possible to prevent regression or prevention of skin breakdown in the first place, and then regression and deterioration once it occurs. So the facility can never divorce itself from all the pressure injury interventions that are required as standard of care.
Schenk:
Hey, out there. Welcome back to the Nursing Home Abuse Podcast. My name is Rob. I’ll be your host for this episode. Today we are talking about the concept in general of unavoidable pressure injuries. I know we’ve had this conversation in the past a few times but we really wanted to dial in on what it means to say that an individual’s pressure wound, their pressure injury, was something that could not have been avoided using.
The nursing standard of care. What does that mean? But we’re not doing that alone. We have the fantastic Heidi Cross on to walk us through.
We’re going straight to the horse’s mouth. We have the fantastic Heidi Cross as our guest to have this conversation with. Heidi Cross is a board certified wound and ostomy nurse and family nurse practitioner in Syracuse, New York with a master’s in nursing from. That is the State University of New York, upstate Medical University.
That’s a mouthful. She got a master’s from there. She has extensive experience in acute and long-term care. She consults for nursing homes and strong Memorial Hospital and has reviewed numerous legal cases, a member of multiple professional organizations. She lectures widely on nursing standards and pressure injury preventions.
And there she has a blog as well. Where she writes about pressure injury, and pressure injury prevention, and long-term care. And that link will be in the show notes and I highly suggest everybody go check that out. And without further ado, Heidi, welcome to the show.
Cross:
Thank you so much for having me.
What is the definition of an unavoidable pressure ulcer?
Schenk:
So we’ve had probably maybe a dozen episodes about pressure injuries. And one of the things that always confuses me, the, one of the things that I feel like we, we should talk about more is this concept of avoidable versus unavoidable when it comes to pressure injuries. So what, in your experience what makes a pressure injury, if ever unavoidable?
Cross:
Just start by saying you’re not alone in that confusion. Even wound experts, there’s a lot of confusion, a lot of varying opinions. What you’re going to hear today is merely my opinion, which I’d like to think is based on sound reasoning and all the literature and learning that I’ve had. So in order to answer that question, I think it’s important to maybe start with the fact that traditionally all pressure ulcers, bed sores.
Current terminology is pressure. Injuries were always considered avoidable. If a patient came in, a resident to a nursing home, whatever, and got one put on the SAT cloth, put on the ashes, we’re on the hook for this. And plaintiff attorney likely would be a knocking on our door. Unfortunately. As far as the definition goes, here’s the Heidi Cross definition, and we will get some more official ones as we go along. The Heidi cross definition is that a pressure injury may be unavoidable if all standards of care were met. And the documentation is in place to tell that, that actually those standards of care actually were followed.
Review the latest research on the impact of preventive health measures in elderly populations.
Was the patient turned and positioned? Was the patient on a specialty surface? Was nutrition adequately addressed? Was the patient appropriately mobilized? Were care plans in place incontinence care? All those things come into play in pressure injury prevention. And if all those things indeed are.
Done and documented and factor in also patient comorbidities and perhaps where they are in life, such as end of life, unavoidable pressure, injuries. If all those standards and interventions are in place, then we do, we are able to say this pressure injury most likely is unavoidable.
Find out in our podcast whether you can sue a nursing home for pressure ulcers.
Does the Center for Medicare and Medicaid Services acknowledge unavoidable pressure ulcers?
Schenk:
I think that that, I feel like that’s not just Heidi Cross definition.
I think that’s the CMS definition too, which is to say if the nursing process is followed and despite the nursing process being followed, the individual develops a pressure injury, it’s unavoidable. So I think that your definition is good as any definition.
Cross:
Yeah. I did write down the official CMS definition, which Yes, is exactly that, where they say that the magnitude and severity of risk.
Comorbidities are overwhelmingly high and preventive measures are contraindicated or inadequate given the risk that the patient has. So yes, when I meant the Heidi cross definition, I meant I wasn’t reading from any document or anything.
Learn about new findings on the effectiveness of repositioning in pressure ulcer prevention.
Schenk:
That’s fair enough. Fair enough. I was gonna say that’s pretty good.
What do wound care experts and organizations have to say?
Schenk:
I guess for me, like what would I think where there’s a lot of conflict. You can maybe I get your opinion on this. Where the conflict lies is where the nursing home would assert that maybe even though they didn’t document everything they did do it. Okay. So maybe there’s an absence of documentation, but they’re asserting that they did do some they did everything they could, but.
The, when the resident develops a pressure injury it’s unavoidable because of the comorbidities. We’ll, just take it face value that we did everything we were supposed to do. It was really the comorbidities, the clinical condition of the resident that caused it. Not anything that we did wrong.
Cross:
Absolutely. And we talk about skin failure quite a bit which, maybe we’ll get to in more detail, but yeah, you absolutely have to look like someone wiser than me said, you have to look at the whole patient, not the hole in your patient. What is going on with this patient?
What comorbidities do we have and are we perhaps even an at an end of life phase where we have a definite, unavoidable skin breakdown due to, like skin failure often is due to organ failure.
Explore current research on pressure ulcer risk factors in long-term care residents.
Is skin failure the same thing as an unavoidable pressure ulcer?
Schenk:
Exactly. ‘Cause I as I’ve said many times, the skin is also an organ, so sometimes when the body’s sitting down it’s possible that, you ulcers develop because of that end of life process.
We’ve actually had Ms. Kennedy on to discuss Kennedy terminal ulcers in the past.
Cross:
That was a really good one. Yes.
Read about recent advancements on wound care treatments for pressure ulcers in elderly patients.
Schenk:
What are some of those clinical conditions that. Would prevent the nursing process from preventing the wound where the clinical conditions is such that the, no matter what you can do, no matter what you do, the person can be in space and they would develop a wound. What are some of those clinical conditions?
Cross:
We’ve already mentioned the end of life. It, it depends on what’s going on with the patient clinically. Are they in the intensive care unit? Is this like an acute type of skin failure? They’re intubated, their kidneys are failing, their nutrition is lagging.
Their inflammatory conditions are just really running high due to their illness. I saw a study just recently that up to 40% of all pressure injuries in the ICU totally are avoidable, which means 60% are, I’m sorry, totally unavoidable, which means that 60% can be considered avoidable, but still that’s a pretty high number, 40%.
Understand key clinical debates in this paper on whether pressure ulcers are avoidable or unavoidable.
So that’s like the ICU situation. Concomitants also in the ICU can apply to other conditions as well as hypotension. Are they severely hypotensive, which means that the organs are not getting enough perfusion to maintain life. And that of course applies to the skin as well.
And actually the body will take preference with whatever blood pressure is available to the patient, the body will take preference with that to the inner organs, much to the disadvantage of the skin. And particularly, in the ICU, if a patient is on vasopressors shunt, it cause vasoconstriction in the periphery so that VA shunt the blood from the from the periphery, from the skin and the soft tissues around the skin to the inner organs in an effort to preserve life and maintain the mean arterial pressure. So that’s one situation. Just age related skin conditions can cause unavoidable skin breakdown. And of course in nursing homes, that’s the type of population we’re dealing with.
And. The skin just tends to break down the sub cutaneous tissue atrophies. And patients are just really prone to skin breakdown. Shearing is a big one. Can cause an unavoidable pressure injury if the head of bed has to be elevated, that shearing will. Cause what shear is a downward sliding of bone against soft tissue as the head of the bed is elevated.
Learn your legal rights by reading whether you can sue a nursing home for pressure ulcers.
So that’ll cause unavoidable skin breakdown. Malnutrition is a big one. If a patient is malnourished and often even towards end of life when we’re trying to maintain nutrition as much as possible. But the patient still may be malnourished. So that can be a real risk factor. And actually we talk about, there’s a good term anorexia of aging where as we get older we’re perhaps nearing that.
Point in our life and metabolic, the metabolism just goes down. And as such, the appetite goes down and the patient isn’t eating like they used to. That’s called the anorexia of aging. Dementia often demented patients just, they’re unable to. And by the way we often think that with dementia, with patients who aren’t eating well, we should put tube tubes in.
Listen to our legal and clinical discussion on whether pressure ulcers are avoidable.
And the American Geriatric Society has actually come out against tube feeding in demented. Elderly individuals, they actually cause more issues than they, they solve. What else? Anemia hypoxemia that type of thing can all lead to unavoidable skin breakdown.
If your loved one passed away after developing bedsores, read about whether you have a claim.
What are the risk factors for unavoidable pressure ulcers?
Schenk:
I think that absent or setting aside any acute trauma, take us out of the ICU and take us out of end of life.
So you have every, everybody else in the world or yeah in the world. You have a bunch of people screaming at their screen right now or at their car radio about how you can have all these things happening. You can have a lot of diabetes, peripheral artery disease, anemia, all these things. All you gotta do is unload and reposition the person because you know that’s the, where the rubber meets the road that’s gonna prevent it, and they’re all avoidable.
Outside of these those two categories what would you say to that?
Cross:
The National Pressure Injury Advisory Panel. Actually in a kind of a landmark article that they came out with differentiated it between intrinsic factors and extrinsic factors and some of these intrinsic factors, you just can’t change.
You can’t change the age of the patient, if they really do have frailties due to aging. Uncontrolled diabetes, you can’t change, you know what’s going on there. You can try to control their diabetes as much as possible. And stage renal disease is another big one. They have a tendency to break down and you can dialyze patients, but they are at very high risk for unavoidable skin breakdown.
All kinds of intrinsic factors that they list. What I’d like to say, maybe. Circle back if it’s okay to organ failure. We accept that hearts can fail unless there’s medical malpractice. Nobody sues the cardiologist over heart failure. Likewise with kidneys, if there’s kidney failure, again, skin is an organ and just the other organs it can fail.
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And we have lab values for heart failure. We have lab values to indicate kidney failure. We do not have any lab values to indicate skin failure. And skin failure isn’t just end of life. There’s a landmark article by Diane Lmo, L-A-N-G-E-M-O came out in 2006, but it really is considered still the Hallmark article, well describing skin failure.
And it differentiate in this article. Diane Lhamo differentiates acute skin failure, which is the acute ICU condition we discussed. She also mentions chronic skin failure where the patient has chronic comorbidities, and that’s more of a gradual decrease in the ability of skin to withstand trauma and pressure.
And then you have the end stage skin failure. So certainly any of those can occur at any time. During life, especially if we’re talking acute and chronic, doesn’t have to necessarily be the elderly. It doesn’t have to necessarily be someone who’s dying.
Dive into detailed prevention strategies in our episode on comprehensive pressure ulcer prevention in nursing homes.
So, how do I determine if a pressure ulcer was unavoidable?
Schenk:
I think that an issue that I find is that I.
If there is a breakdown in the nursing process, okay, so let’s say that there is let, the turning repositioning schedule is not efficient or it wasn’t done correctly, or they didn’t offload as much as they should. And there are also those clinical conditions that we mentioned. Okay. And they present.
That’s where the fight is really because. How can we say the injury is unavoidable If there is a breakdown in that nursing process.
Cross:
Talking a breakdown in the nursing process or a lack in the nursing documentation. We’re taught from day one in nursing school, and it is the plaintiff attorney mantra, not documented, not done.
And certainly if there are holes in the documentation, then you know you’re gonna really question was this patient actually being appropriately managed and turned and positioned? I guess my counter to that would be that when I look at a chart retrospectively as a legal nurse consultant, I look for a culture of turning and positioning, is what I say.
Understand the causes, prevention, and legal implications of bedsores in nursing homes.
Even though it’s not absolutely perfectly documented every two hours or whatever, is it mentioned in the nursing notes perhaps at least once a day or better yet every shift, is it in the care plan? Do the CNAs seem to have documentation that they’re actually turning and positioning the patient?
Is the physician involved? And certainly nurses don’t need an order for turning and positioning in order to turn the pa the patient, but in my mind anyway, if. If we have a physician’s order for it, I think that’s stronger documentation and that it shows. Indeed, we’re dealing with a multidisciplinary team all working toward the same goal, which is pressure injury prevention, which includes turning and positioning.
Learn five effective ways to prevent pressure ulcers in nursing homes in this podcast episode.
Schenk:
Okay, so let’s say that the nursing home has admitted that their turning repositioning program is not a part of the culture. They didn’t do it as they should have. Okay. But also, again, the resident has all these clinical conditions that make them extremely susceptible to pressure injuries.
That’s a lot of times that’s where the conflict is. And do you have an opinion? Like how can we say then at that point, because we do have a breakdown. In the nursing process, but at the same time, we have a lot of clinical conditions that would precipitate it. Is it unavoidable or avoidable in that ca in that situation?
Cross:
Rob? I. Even with clinical conditions, we still need to do everything possible to prevent regression or prevention of skin breakdown in the first place, and then regression and deterioration once it occurs. So the facility can never divorce itself from all the pressure injury interventions that are required as standard of care.
Does that answer your question? Regardless of comorbidities.
If you suspect neglect, consult a Georgia nursing home abuse lawyer for bedsores for your case.
What do I need to look for in the chart to determine if this is unavoidable?
Schenk:
Very well said. I think that a lot of times that’s where we live. Not all of my cases are lack of documentation. A lot of my cases are, they didn’t do what they’re supposed to do, but the nursing home still defends on the fact the resident has the, the riot act of comorbidities or clinical conditions.
Cross:
I do, as maybe you’ve already caught on. The majority of the time I do defense work. I actually do very little plaintiff work, but even as a defense legal expert witness, if I do not see that the standards of care if I see that they’re not being met regardless of the patient’s condition the facility still has to meet those standards of care and do what they can to I.
Said A, prevent pressure, injuries, and b, attempt to prevent their deterioration once they occur.
Hear practical strategies in our podcast on preventing pressure ulcers in nursing homes.
Schenk:
Heidi, this has been very a very fun conversation. I really appreciate you coming on and sharing your knowledge with us.
Cross:
Thank you so again, so much for having me. It was fun.
Schenk:
Folks, I hope you found this episode educational or entertaining, or maybe both.
If you have an idea for. Topics that you would like for me to talk about, let me know. If you have any idea for guests that you would like for me to talk to, please let me know. If you want a coffee mug, just let me know that as well. Those are three things, topics, guests, and do you want. A nursing home abuse podcast, coffee mug.
I think at some point there’s just gonna be two boxes of coffee mugs being dropped off at the Goodwill. So be sure to get yours before they go there. And then you gotta pay, maybe it’ll be half off when you go there. At any rate, new episodes of the Nursing Home Abuse podcast every single Monday.
And with that folks. We’ll see you next time.
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