facility acquired pressure ulcers

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Specializes in multispecialty ICU, SICU including CV.

Hi, I'm a hospital nurse.

My grandmother in law is W/C bound after a bout of Guillian-Barre about 18 months back. After it was determined that she was never going to walk again she was placed in a local LTC -- she is a paraplegic, but unable to do her own transfers due to her age and strength, so she is a hoyer lift. She has pressure ulcers to the bone on her backside (this is per reliable report, haven't actually seen them). She schleps several times a week to a hospital wound care center for dressing changes, etc.

My concern is that these were definitely facility acquired -- not sure if they started back in the hospital or at the LTC but they definitely worsened significantly at the LTC. The time frame I think is despicable. To have something this horrible after not having been a para or quad for a lifetime (who as everyone knows, are at very high risk) --> this bad in 18 months? Really?

Who pays for this? Is she getting billed for wound care/transportation?

What about how this has impacted her quality of life?

How does one go about reporting this or receiving restitution? Can you go to the state?

What do all of you that are facility DONs/ADONs have to say about something like that?

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PIs can go to the bone in a week, even after treatment has begun on a small stage I.

I suggest that you go an see them before reporting the facility.

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Specializes in multispecialty ICU, SICU including CV.
PIs can go to the bone in a week, even after treatment has begun on a small stage I.

I suggest that you go an see them before reporting the facility.

I am aware that they CAN do that, but they shouldn't with the appropriate inventions and prevention strategies in place.

I have been to the facility. I'm not really sure what you are suggesting with the "go and see them" comment -- are you saying I should examine the wound? I'm not sure what point that would serve.

I don't feel that it is my place to go to the DON/ADON if that is what you are trying to say. My mother-in-law is her point of contact for healthcare and she handles all of that stuff.

I guess another question -- is that kind of stuff reportable to the board?

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Anything is reportable to the state's department of public health. Whether it is actionable is another question.

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Specializes in LTC, ER, ICU, Psych, Med-surg...etc....

The first question is were they avoidable? What is the patients condition? What are her labs. She now needs LTC and did not before, this is a clear indication that her condition has deteriorated. What was their risk assessment for development of pressure ulcers? What is the care plan? What interventions are in place prior/during and after? Just because a person develops a pressure may not mean that it was the facility's fault. There are times when it is unavoidable. Get more info....

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Specializes in multispecialty ICU, SICU including CV.

I do think it was avoidable. This woman went into the GBS diagnosis as an 80 year old in her normal, active state of health -- living at home, driving, etc. Non-diabetic. Never went through an NPO period in her treatment. She went into a facility after she failed a rehab stay and was permanently W/C bound. Her 80 year old husband couldn't take care of her at home.

I have sat on my hospital's skin care committee for years and I am very well aware of the new research on unavoidable pressure ulcers. That applies to people with horrible vascular disease/severe blood flow problems, horrible nutrition, possibly pressor use. None of these things were the case.

I get the impression that no one really wants to touch this thread. We all know that people get pressure ulcers because of immobility and poor preventative nursing care. I believe this was the case. What I want to know is -- how does that get handled by the nursing management?

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It depends on the facility.

As soon as we identify any non-blanchable area an investigation is launched to determine whether the wound was avoidable and treatment is started. Nutritional eval, pre-albumin, PT eval for pressure-relieving devices and, if it does not resolve, wound care consultation.

What was off-putting was your request about how to get restitution, and the immediate presumption of negligence.

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Specializes in multispecialty ICU, SICU including CV.

Negligent -- likely. I'm not blaming, I'm just being realistic. I've worked in the industry long enough to know it happens.

I am not personally going to do anything as far as restitution about this issue. I found out today that my mother-in-law's sister-in-law (the patient's daughter-in-law) already filed a complaint with the state.

Have found out that some staff in the facility have told my mother-in-law that she has "fragile skin" and the ulcer on her coxxyx just "happened." Really???

It seems like she is at least owed an apology or an explanation from the facility for what happened. And, I would think she wouldn't have to cover the cost of treatment.

Apparently she has healed heel ulcers, an ulcer on her coxxyx (don't know what stage, it is at least a II because regular dressing changes are being done), and an ulcer on her IT that started when PT was re-teaching her how to sit up, may have been related to the W/C she had not being appropriate for her or having the appropriate protection on the sitting surface. That is the bad one -- stage IV, now with a VAC dressing.

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Specializes in LTC, Hospice, Case Management.
I don't feel that it is my place to go to the DON/ADON if that is what you are trying to say. My mother-in-law is her point of contact for healthcare and she handles all of that stuff.

If you have some training/knowledge on this subject why don't you take the mother-in-law in with you and request a care conference with the DON/ADON. Simply ask.. how do you think this happened, what were the contributing factors that caused this, what is her current plan of care to get these areas healed and are they showing signs of healing? You may find they have all the right answers and you may also find you are not satisfied

I'm not a bit afraid to "touch this thread". I'm not sure either one of us really have all the facts to understand how this happened which is why you need to go ask those that actually may have the answers. Your original post seems to be more concerned with restitution and punishment of the facility rather than the focus of this loved one & the care.

Could this be outright negligence? Of course. And you may even find that the facility doesn't really give a rip. In which case you would want to notify the state department of health (those numbers should be posted in the facility).

It also could be an honest mistake. Try as we might, the staff messes up sometime. They are humans not robots. Some staff just need additional education, some need written up and some just need to be let go. I know this doesn't mean much when it is your loved one but it is the truth & I'm not always sure that this justifies calling in every authority known to mankind when the facility is making every effort to correct the situation and prevent it from happening again.

It also could be an unavoidable pressure ulcer & you just aren't aware of all the other circumstances in her medical history that play into this.

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Specializes in Vents, Telemetry, Home Care, Home infusion.

cared for several patients in my career that despite best efforts to prevent, developed stage 4 decubs in less than a week. my 80+yo nana hid fact that she lost ability to cook --would only eat michelinas frozen dinners --realized was only getting in about 800 calaries a day when she began to fall..... another client with muscular dystropy developed vent dpendent resp failure from going on a low protein diet to loose weight not realising depeleted protein stores in diphragm muscle.

my grandmother in law is w/c bound after a bout of guillain-barre about 18 months back. after it was determined that she was never going to walk again she was placed in a local ltc -- she is a paraplegic, but unable to do her own transfers due to her age and strength, so she is a hoyer lift.

this woman went into the gbs diagnosis as an 80 year old she went into a facility after she failed a rehab stay and was permanently w/c bound. her 80 year old husband couldn't take care of her at home

has fragile skin

the red areas indicate high risk for skin breakdown that often can not be prevented in someone of this age.

person doesn't have to be npo to be in poor nutritional shape. do you have first hand knowledge of her dietary habits? seen nutritional lab work on admission and followup? does she eat a high protein diet necessary for wound healing? does she refuse to be turned, repositioned or shift weight to prevent shearing forces on fragile skin due to paraplegia?? don't blame the nursing home until you have all the facts.

best advice: ask for a care conference with family, staff and wound care consultant to get all the facts, understand wound care prevention program in place and what family can do to help. if not satisfied with answers, ask second opinion, report to facility ombudsman or if indifference to concerns, then file complaint to department of health.

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I'm not afraid to respond either. The facilty could be 100 % responsible BUT...

First off, since you are not the POA and your MIL? is, you will need to get the permission or ask her and the resident if you can be involve. Before you get the attorney, look into things. Things in acute care are different and you don't always see the results of the acute illness until they are in the LTC or rehab and the skin breakdown process has already begun.

At the very least, each facility is responsibe for doing an admission assesment that includes a skin assessment and a risk assessment for breakdown. (braden, norton, etc) from that the care plan is developed and interventions should be put into place to prevent or treat skin breakdown. Since she is getting therapy, they probably will be included in this esp for positioning and transfers.

If she is medicare skilled, she would have the assessments and careplans completed more often.

Are you 100% sure that she had no skin breakdown while in the hospital? I can't begin to tell you how many residents we get with breakdown that is in hospital aquired. SRSLY...we have quite a few hospitals that we get patients from too.

After this, most places assesses the skin weekly. (I think this is a reg). How long after she was admitted did treatment start? Is she compliant with all the interventions that were put in place? What is the food like there?

There are tons of things I would ask but the first step is to actually go in and speak with the DON. Are pressure sores a wide spread problem for this place? Have you checked out the most recent survey? Does it seem like this place is understaffed?

Above all, if you don't feel like your loved one is getting good care, you might want to start looking at some different facilities.

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Specializes in multispecialty ICU, SICU including CV.
I

Are you 100% sure that she had no skin breakdown while in the hospital? I can't begin to tell you how many residents we get with breakdown that is in hospital aquired. SRSLY...we have quite a few hospitals that we get patients from too.

There are tons of things I would ask but the first step is to actually go in and speak with the DON. Are pressure sores a wide spread problem for this place? Have you checked out the most recent survey? Does it seem like this place is understaffed?

Above all, if you don't feel like your loved one is getting good care, you might want to start looking at some different facilities.

Michelle, thank you for posting -- that is a big question that I have too. When did these start? Not sure. I'd be interested to know if it was documented in the hospital or the NH. She has never been home, so this is for sure facility acquired -- which one, I don't know. I think the really bad one was only since she started sitting up/chair training etc. and that has been since she was at the NH, but the others, I have no idea.

I did check the survey on the state website. The scores were all passable (3 stars of 5 or better) with the exception that they don't have hardly any private rooms (1 star.)

I know that NOW she is getting assessed and has all kinds of preventative precautions in place and lots of wound care. Best I can tell, everything is appropriate for her condition...now. I'm wondering though if it was too little, too late.

Like I previously posted, grandma's DIL reported them to the board. I don't know where that is going, if anywhere. I should ask my MIL if she knows.

As far as looking for another facility -- that is a whole another bunch of drama. MY sister-in-law (the patient's granddaughter-in-law) is the DON at the sister facility to the one she is in (this parent company has 5 LTCs in this metro area) and sort of got her in there. I don't know if she was expected to receive better care there because of this relationship or if the facility was pushed on her by my SIL's recommendation. I guess if this was my parent, I would favor pulling her out if I could pin fault on the facility for sure.

FYI to all posters/readers -- I am not lawsuit happy and I certainly don't want to bash our profession. I'm not seeking repercussions -- just wondering, really, what the options are and if people think they are indeed owed. I DO have high standards for care though, and to me this whole situation is just a horrible, messy, icky thing and I really just wish she was cared for appropriately so these things didn't happen, if they did (and I think that is likely.)

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