Co-Morbidities, Unavoidability, and Pressure Injuries

Episode 205
Categories: Bedsores

Are bedsores always preventable? The impact of co-morbidities might surprise you. In this week’s episode, nursing home abuse attorney Rob Schenk welcomes guest Andrew King to talk about the challenges of preventing pressure injuries and how unavoidability plays a role.

Co-Morbidities, Unavoidability, and Pressure Injuries

Schenk: Comorbidities, unavoidability, and pressure injuries. Stick around.

Hey out there. Welcome back to the nursing home abuse podcast. My name is Rob. I will be your host. For this episode, we’re talking about the terms comorbidity and unavoidability and what those mean and air quotes and what they actually mean as it pertains to pressure injuries and bringing pressure injury cases.

But I couldn’t talk about this by myself. So I had to bring in the big guns. That is attorney Andrew King, fantastic attorney, nursing abuse attorney here in Atlanta, Georgia. Great guy. So stick around for that conversation because we’re really getting into the weeds about those terms.

Now it’s time to get into the meat and potatoes of the episode. And when I think meat and potatoes, I think of Andrew King. Andrew King is a fantastic trial lawyer, over at Lourie, Chance, Forlines, Carter & King a predominant amount of his practice is dedicated to abuse and neglect committed in Georgia long term care facilities.

He and his firm have acquired verdict after verdict in that sphere, and they are highly respected. And as far as I’m concerned, that law firm is on the Mount Rushmore of nursing home lawyers in the state of Georgia. So I’m very happy to have Andrew on the show today, Andrew, welcome to the show.


Thank you so much for having me. 


As I mentioned at the top of the show, your law firm is on the Mount Rushmore of nursing home law firms in Georgia. And you have the verdicts to prove that in one of the verdicts, at least a couple of the verdicts in the past couple of years have been on pressure injury cases.

What does the term co-morbidity mean?

So I wanted to get you in to talk about some of the more defense centric aspects of pressure injury cases particularly the idea of comorbidities. So you’re the man to do this with. The first question is we hear the term comorbidity, but what does that mean to you?

And what do you think it means, like historically, like what, when somebody says this person has comorbidity X, one Z, what are they saying? And what do you think they’re really saying?


In terms of the sort of medical definitional thing, I actually looked it up in preparation for today because I’d never looked up the word, but apparently the word was coined in 1970 by a guy called Feinstein.

And he defined it as a distinct clinical entity. And, that doesn’t really mean much to me cause I’m not a doctor. And yeah, in very simple terms, comorbidity is two or more disorders that occur in the same person simultaneously or sequentially. So that’s the medical definition.

If you want to talk about what the defense means by comorbidity, what they’re saying is that person’s life was not as worth as much as you think it was. And that’s really the way comorbidity gets slung around in litigation aspects. But it’s truly interesting when people talk about it. Oh, yeah, the person that we accepted to a nursing home or a long term care place, they were really sick.

And so your case just isn’t worth much. And, it’s that wonderful double standard that I’m sure you deal with. 


Yeah and it’s funny that you mention that because it really is oh, he had comorbidity X, Y, and Z. And they say that and it seems like on the surface, they want to say this individual had these clinical conditions, which may or may not have had an effect on the ultimate injury.

But what they’re really saying is all of the, all the comorbidity X, Y, and Z caused the injury, right? And that’s really what’s the context of the surface. And then obviously, as you mentioned the value component. So I guess from what I’ve seen, and I’ve been doing this podcast for a while and I have guests come on that Like we shouldn’t say cognitive impairment.

We should say something else. We shouldn’t say accident. We should say motor vehicle collision. We, you know what I’m saying? We’re trying to change the paradigm. And I really think that comorbidity actually is one of those things. Even though I’m guilty of saying it myself, it’s just one of those words that it just, I think that we say it and it means different things to different people.

And it can be used to cut it, cut the case down.


No, you’re exactly right. It’s a medical term that people have attached a connotation to. A good example of it is the word manipulation. Manipulation has this negative connotation, but if you go look at the definition of it in the dictionary, it’s just a change or an alteration to something.

And so in the same vein, I think what people have done is taken a word just truly a medical word and used it in the litigation space to, to say negative connotation to this person’s health. And it’s ironic in my mind because When you’re talking about our elderly community, something I like to say, and it’s often as much as I can, is only the lucky get to grow old and truly, as you grow old, you’re going to have problems.

And that’s, in fact, why nursing homes exist and long term care facilities exist is because they’re going to take care of the people that fortunately got to grow old. But as a natural part of life, they’ve got problems. 

What does the term unavoidable mean?


Let’s segue from a word that is nebulous to a word that does have an actual meeting under the federal regs, and that is unavoidable.

So tell us about what unavoidable means as it pertains to a pressure injury case. 


So a term of art, actually. What unavoidable means, it’s four things. And this is was first promulgated by the CMS and then also is now promulgated by the National Pressure Injury Advisory Panel, which is a mouthful to say.

So I’m just gonna call the advisory panel. But essentially, to be in an unavoidable wound, you have to prove. So the defense really has to prove four things. One, that the wound in the patient’s condition was evaluated properly and the risk factors were properly identified. Second, that those things were defined and appropriate interventions were created and implemented.

Three, the results of those interventions should be monitored. And for any revisions to those interventions should be put in place and essentially go through the same analysis over and if the defense can show those things that they were doing those four things, that’s what makes a wound avoidable.


And this is what gets interesting for me. And most of the time, I’m going to say almost 100 percent of the time, you’re going to have a break in that chain that you mentioned. Okay. From assessment to plan to revision of the plan or execution of the plan and the revision of the plan that’s falling apart.

And they’re going to say, Rob, even if we did those things, you could put this person in space and they’re going to develop a pressure injury. Okay. Okay. What do you say to that? What do we, as plaintiff’s attorneys, do we stick with, okay, all I have to show is that you, there’s a break in the chain or do you yourself in your experience, do you show the break in the chain and say, even if.

That the chain was there, or if the chain wasn’t unbroken, this wouldn’t have happened. Like how do you approach that? 


So definitionally you’re exactly right. If there’s a break in the chain, it’s avoidable and definitionally. So it’s, it is, or it isn’t. And just like a definition, if you meet the definition, you are, and you are avoidable.

And if you don’t meet the definition, it’s unavailable, it’s avoidable, excuse me, the other way around. And yes, you get into this kind of tension. With the defense where they’re looking at truly what are risk factors not causes of pressure injuries and they say hey look, this person was really sick Hey, this person was immobile.

They were this they were that and what they’re missing The point is that this idea of unavoidable versus avoidable is a term of art and when you look at the term of art You have to look at each element to see if they’re really meeting it and so i’m with you If there’s a break in the chain it’s an avoidable job.

Are risk factors and causes of pressure injuries the same thing?


Your job is done. It’s defined as unavoidable. You mentioned something there that I just completely toppled over. I tumbled over it. Like I’m, skidding on a banana peel with the newspaper on my face. And that is, and yeah, and that is as far as the, as far as you and I know it’s Friday. And then so the idea of risk factors versus causes of the pressure injury.

Can you elaborate on that? Is there a difference between the two and what, if so, what is it? 


So there is again, it’s one of those things where you have to dive into the medicine and pay particular attention to what’s going on because truly, it’s one of those things that people use loosely in the terminology there.

As far as I can tell, there are three big causes of pressure injury and that’s pressure very, obviously. friction and shear. Those are causes of pressure injuries. Now, a patient or a person can have risk factors and risk factors are something that increase the likelihood that those causes will cause a pressure injury.

And so risk factors are things like immobility, incontinence, nutrition, hydration, vascular disease, and other things like that. Certain medications can cause a higher risk of a pressure injury. But when you’re looking at causes, it truly is those three things. Pressure, shear, and friction. 

Can risk factors alone make a pressure injury unavoidable?


Okay that being said, and based on what you’ve defined as unavoidable, or what the CMS has defined as unavoidable can risk factors alone make a pressure injury unavoidable?


It’s tough because what you got to do is you have to go look back to the definition of avoidable versus unavoidable and figure out whether those risk factors were identified. Risk factors in and of themselves don’t make a wound avoidable or unavoidable. What they do is they contribute to the analysis as to what is truly unavoidable or avoidable.

And if somebody has a vascular disease and they’ve got a wound on their heel, it aids into the analysis. When you’re looking at something medically, yeah, when somebody’s got vascular disease and especially peripheral vascular disease. they’re more likely, but not it’s not causing, but they are more likely to suffer heel or far extremity wounds.

But in and of itself is not a cause, and in and of itself does not make it unavoidable. The question then becomes, are the caregivers properly evaluating and intervening on this? 


So I guess then, if it is the case that we have let’s say incontinence, a bowel and bladder incontinence is a risk factor.

The nursing home would assess that and say, okay, it exists. Here is the reason for it. And we’ll just say that it has to do with physical incontinence, like the weakness for or after a surgery or something like that. And then based on that assessment, the intervention might be adult briefs and rounding every hour.

All right? And they do that. Okay. If a pressure injury develops at that point then there is a possibility of an argument that it was unavoidable because if we believe that adult briefs and regularly monitoring hourly, for incontinent episodes.

After assessing the type of incontinence, then they’ve done their job, right? Is that kind of what we’re going towards possibly? 


Possibly you’re getting there, you need to add a few things to the equation. Obviously, if they’re monitoring every hour and then changing the brief and then properly prepping the skin and then properly making sure everything’s dry and clean.

Yeah. That you’re getting pretty far into the it’s unavoidable analysis on that front, quite frankly, the thing that you have to then look at is, are there other risk factors that are going on? Are there other things? Like you said, if you can put a patient in space and completely remove the potential for pressure, friction and shear in a medical world, you would think pressure injuries wouldn’t happen.

And so when you’re looking at things like incontinence, immobility and pressure points, then you really have to determine is the holistic part or is the holistic condition of the patient really being looked at and treated? Because great, you could be changing briefs every five minutes, but if you’re not dealing with an over medication of a vasosuppressor, then you might still have something going on.


I guess at least for in my experience, I feel like where the problem arises typically isn’t the assessment. Usually they get it right that the person is a high risk for pressure injury where the problem lies is the interventions chosen and executing on the interventions. That’s typically so I’m dealing with sufficiency of care planning and sufficiency of the execution of the care plan is where the avoidability unavoidability comes into play for at least in my cases.


Yeah, it’s become problematic, especially with E. M. R. And, we could probably spend three hours talking about the problems with the M. R. But I’m sure what you’re seeing is drag and drop care plans. And that in and of itself, I think, is problematic. The analysis for the defense, because if you’re making non personalized, non specific care interventions, Oh, Dakin’s every other day or something like that.

]And it’s a drag and drop. I think you’re running afoul of the regulations, frankly. 


Okay. So in a perfect world, you’ve got your scrubs on, right? How are you, what’s your approach then to pressure injuries


It’s tough. And I don’t want to breeze over the fact that caregiving is tough, providing care to people, especially people that have mental disabilities or dementia, Parkinson’s, it’s difficult.

In fact, I used to represent hospice nurses, doctors, I used to represent them all and I will underscore the fact that thank you all for providing care to our elderly and to us. But sometimes it’s tough. Everybody messes up. And if I were to become Dr. King and was, or nurse King or whatever King and providing care to somebody, long ago, I read about this terminology called adaptive management, and it’s really used in the context of use of resources and ecology, but I like the concept and the idea that, we’re But what you do is you constantly learn and constantly shift your mentality and your data to come up with a way to move forward.

And it’s a very loose paradigm for how I think people should be treating patients. Like they said, in fall cases it is. The patient’s different every five minutes, so we can’t account for them. So we can’t fall for them. But the point is you’re supposed to be caring for them.

And what you need to be doing is going in there, evaluating the patient. And when you’re not there properly communicating and documenting what so there’s a continuity of care. And when you do all these things, when you perform the evaluations, you perform the interventions, you monitor, you communicate, And you get the entire interdisciplinary staff involved in a proper way.

That’s when you get to the adaptive management point. You’re managing the patient in a way that accounts for all of the changes that they can get into. 


Adaptive. That’s a great word because like to me, what it seems like what you’re saying is you like the or you put strength on the revision component of the nursing process, right?

Oh, it’s okay that it’s not working. As long as we figure out what else could work, right? So like you have your IDT team you’ve got the assessments in place, but like, all right, what’s happening? We’re in an adaptive environment. Okay the briefs didn’t work. The rounding every hour didn’t work.

Then maybe take the briefs off. Maybe we’ll do a queuing schedule, blah, blah, blah. It’s about adapting to what’s actually happening and what’s working. What’s not working. 


Absolutely. And, obviously most of this stuff is science driven, but if something’s not working, do something different, the sort of cute definition of idiocy is trying something again and expecting a different result. 

That’s what I, what you have to look into. So if Dakin’s solution is not working, if turning and repositioning every two hours is not working, go look elsewhere. 


Exactly. Andrew, this has been extremely informative.

I really appreciate you coming on the show and talking to us about this. 


Thank you Rob. It’s been a pleasure. 


Alright folks, I hope that you found this episode educational and perhaps entertaining. If you want to get in contact with Andrew about any potential nursing home case in Georgia, you can email him or check out his firm’s website at Or you can give them a ring at 678 726 5541. 

New episodes of the nursing home abuse podcast come out every week. If you have any suggestions for content, if you have something that you want to see me talk about with a guest, be sure to let me know. If you’re watching this on YouTube, leave a comment, a nice one, and maybe thumbs up, maybe subscribe.

And with that folks. We’ll see you next time. Thanks for tuning in to the Nursing Home Abuse podcast. 

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