Elder Law FAX -- February 13, 2006

Pressure Sores Threaten the Health of Nursing Home Resident
A civil monetary penalty assessed against an Ohio nursing home because a resident developed pressure sores has been upheld by a federal appeals court. Writing for the Sixth Circuit Court of Appeals, U. S. Circuit Court Judge David Nelson upheld an administrative law judge's finding that Tri-County Extended Care Center had allowed the resident to develop an avoidable pressure sore and failed to promote healing of the resident's pressure sores.

Pressure sores, sometimes called decubitus ulcers, typically occur due to unrelieved pressure on a part of the body. Individuals who are confined to a bed or a chair are particularly susceptible to pressure sores, because they are unable to reposition themselves in a way that relieves pressure on their skin. Unless others assist them by turning them regularly, pressure sores are almost certain to develop.

Pressure sores are a particular risk for disabled elderly residents of nursing homes. Because of the high risk of pressure sores, the federal government has imposed a rule on all nursing homes that accept Medicare or Medicaid funds. The rule, in Title 42 of the Code of Federal Regulations, at section 483.25(c), is as follows:

Based on a comprehensive assessment of a resident, the facility must ensure that -
(1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and
(2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.

State surveyors found that Tri-County failed to comply with both prongs of this requirement in regard to its resident. They found that the resident had entered with a pressure sore area on her heel but none on her coccyx, and was assessed as at risk for skin breakdown due to incontinence, dependence on staff, and multiple medical problems.

A red area developed on the resident's coccyx, which progressed to an open area a week later. The resident's physician ordered a therapeutic mattress and various medications.

The facility planned interventions, including checking the resident's brief every two hours and as needed, and providing pericare whenever incontinence occurred. The resident's care plan also called for "meticulous skin care" and repositioning of the resident in her bed or chair at least every two hours, as well as applying medication as prescribed, providing adequate nutrition, monitoring carefully and using gentle touch to prevent skin damage.

The surveyor observed the resident for more than three hours beginning at 7:10 AM during which the resident lay on her back in bed without a pressure relief mattress. The resident was crying out for help with incontinence care, her brief was visibly saturated with urine throughout the period, and the staff did not reposition her during this time.

According to the surveyor, a nurse aide entered the room during that time and heard the pleas but left, promising to return and give care but not doing so. The surveyor also saw the pressure sore when the wet and soiled brief was removed and the dressing on it was not the kind ordered by the physician.

Treatment for Pressure Sores
According to MedlinePlus Medical Encyclopedia, once a decubitus ulcer is identified, steps must be taken immediately:

· Relieve the pressure on that area. Use pillows, special foam cushions, and sheepskin to reduce the pressure.
· Treat the sore based on the stage of the ulcer. (There are four stages, Stage IV being the most serious.)
· Avoid further trauma or friction. Powder the sheets lightly to decrease friction in bed.
· Improve nutrition and other underlying problems that may affect the healing process.
· If the pressure ulcer is at Stage II or worse, specific treatment must be given the patient for cleaning and caring for open ulcers.
· Keep the area clean and free of dead tissue. Generally, pressure ulcers are rinsed with a salt-water rinse to remove loose, dead tissue. The sore should be covered with special gauze dressing made for pressure ulcers.

Prevention
Best is to take precautions to avoid pressure sores altogether. Medline Plus recommends that if the individual is bedridden or immobile with diabetes, circulation problems, incontinence, or mental disabilities, he or she should be checked for pressure sores every day. Look for reddened areas that, when pressed, do not turn white. Also look for blisters, sores, or craters. In addition, take the following steps:
· Change position at least every two hours to relieve pressure.
· Use items that can help reduce pressure -- pillows, sheepskin, foam padding, and powders from medical supply stores.
· Eat healthy, well-balanced meals.
· Exercise daily, including range-of-motion exercises for immobile patients.
· Keep skin clean and dry. Incontinent people need to take extra steps to limit moisture.

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