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Pressure Ulcers in Nursing Homes: Does Negligence Litigation Exceed Available Evidence?
- Wed, 9/3/08 - 10:24am
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I t's official. A crisis exists in nursing homes, fueled by critical staffing shortages that a recent General Accounting Office (GAO) report indicates are expected to become more serious as the population ages and the demand for nursing services increases.1 Additionally, bankruptcies among skilled nursing facilities numbered around 2,000 in 1999 alone. According to the President of the American Health Care Association, this "…is just the tip of the iceberg."2
Patient safety concerns were triggered following the release of the Institute of Medicine's 1999 report "To Err is Human: Building a Safer Health System."3 A recent Congressional investigation demonstrated that nearly 9,000 citations of abuse were issued over 2 years among the nation's 17,000 nursing homes starting in 1999.4 Among the abuses identified were "untreated bedsores."
The lack of clarity regarding the natural history of pressure ulcers has led to the "criminalization" of this event, reported to be as high as 23% in skilled nursing care facilities and nursing homes.5 The occurrence of a pressure ulcer in a nursing home can trigger investigations of negligence, citations, fines, and accusations of abuse.
Pressure ulcer litigation is a growing concern for nursing homes. The incidence of a pressure ulcer alone is used as defacto evidence of neglect on the part of a nursing home. These cases rely on disparate medical records from all treating facilities, testimony of employees of record (when available), and the interpretation of events by expert witnesses. A neat linear format is created by this attenuated reconstruction of events. However, a confluence of factors can lead to the occurrence of a pressure ulcer. Additionally, limited evidence is available regarding the effectiveness of specific prevention strategies. Knowing the outcome in a case being litigated, plus the limitations described above, weakens one's ability to objectively judge whether reasonable prevention strategies were employed in a timely manner or even whether prevention was possible.
Pressure ulcers are a phenomenon, not a disease or even a discrete medical condition. Pressure ulcers - skin breakdown that occurs entirely as a result of exposure to a toxic combination of physical forces, such as pressure and shear - are more accurately described as an injury as used by the Institute of Medicine (IOM).3 Experienced clinicians know that this type of pressure ulcer is the exception rather than the rule. Instead, the incidence of pressure ulcers in nursing homes is more accurately described as an event, often associated with medically complicated residents who usually are frail and immobilized. Clinicians must continue efforts to understand pressure ulcers, learn which can be avoided, and find better ways to treat them. Criminalizing this event will never provide an environment that encourages funding of the basic research needed to comprehensively understand their natural history nor will it help people at risk for developing pressure ulcers or those responsible for patient care.
The Current Nursing Homes Oversight Environment
The nursing home industry ranks high on the list of the most regulated industries by both state and federal oversight agencies. The federal government is a major stakeholder in the nursing home industry. In the year 2000, the federal government paid nursing homes an estimated $39 billion.6 Through the Centers for Medicare and Medicaid Services (CMS), the federal government performs an increasingly coordinated oversight role.
References:
1. General Accounting Office. Nursing Workforce: Recruitment and Retention of Nurses and Nurses Aids is a Growing Concern. May 17, 2001. Publication No. GAO-01-750T
2. Roadman CH, President and CEO, American Health Care Association Testimony before the Senate Select Committee on Aging. September 5, 2000. http://www.ahca.org/brief/test090500.htm. Accessed October 5, 2001.
3. Kohn LT, Corrigan JM, Donaldson MS, eds. Committee on Quality of Health Care in America. To err is human: building a safer health system. Institute of Medicine. November 29, 1999. ISBN No. 0-309-06837-1.
4. Bacon J, Willing R. Report finds nursing home abuse on the rise. USA Today. July 31, 2001. Health/Science section:A3.
5. Bergstrom N, Bennet MA, Carlson CE, et al. Clinical Practice Guideline Number 15: Treatment of Pressure Ulcers. Rockville, Md: US Department of Health and Human Services. Agency of Heath Care Policy and Research; 1994. AHQR Publication No. 95-0652.
6. Scanlon, William J. Success of Quality Initiatives Requires Sustained Federal and State Commitment. FDCH Congressional Testimony to the U.S. Senate Special Committee on Aging. September 28, 2000. Publication No. GAO/T-HEHS-00-209. Title: Nursing Home Care.
7. Katz S, Adams CE, Beigel A, et al.Improving the Quality of Care in Nursing Homes. Institute of Medicine. Publication No. IOM-85-10. Washington D.C., National Academy Press, 1986.
8. Harrington C, Woolhandler S, Mullan J, Carrillo H, Himmelstein DU. Does investor ownership of nursing homes compromise the quality of care? Am J Public Health. 2001;91:1452-1455.
9. Wunderlich GS, Kohler PO, eds. Committee on Improving Quality in Long-Term Care, Division of Health Care Services. Improving the Quality of Long-Term Care. Institute of Medicine. Washington D.C. National Academy of Sciences. 1999:ISBN No. 0-309-06498-8.
10. Bennett RG, O'Sullivan J, DeVito EM, Remsburg R. The increasing medical malpractice risk related to pressure ulcers in the United States. Journal of the American Geriatric Society. 2000;48:73-81.
11. Lyder C, Preston J, Grady JN, et al. Quality of care for hospitalized Medicare patients at risk for pressure ulcers. Arch Intern Med. 2001;161:1552.
12. Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Clinical Practice Guideline Number 3: Pressure Ulcers in Adults: Prediction and Prevention. Rockville, Md: Us Department of Health and Human Services. Public health Service. Agency for Health Care Policy and Research; 1992. AHCPR Publication 92-0047. Cited by: J Am Geriatr Soc. 1995;44:1118-1119.
13. 42 C.F.R. Code of Federal Regulations/483.25(1998).
14. Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Clinical Practice Guideline Number 3: Pressure Ulcers in Adults: Prediction and Prevention of Pressure Ulcers. Rockville, Md.: US Department of Health and Human Services. Agency for Healthcare Quality and Research; 1992-7. AHQR Publication No. 92-0047.
15. Shekelle MD, Ortiz E, Rhodes S, et al. Validity of the agency for healthcare research and quality clinical practice guidelines. JAMA. 2001;286(12):1465.
16. Stefanova K. Negligence lawsuits against Florida nursing homes increasing insurance premiums across the country. The Washington Times. September 4, 2001. Accessed at www.kaisernetwork.org/dailyreports/healthpolicy. Accessed September 4, 2001.
17. Regulatory Developments: Survey, Certification and Enforcement, Scope and Severity of Study. American Health Care Association. Regulatory Update. July 2001. Accessed at www.ahca.org/news/ru0107pb.pdf. Accessed September 19, 2001.
18. Aaronson WE, Zinn JS, Rosko MD. Do for-profit and not-for-profit nursing homes behave differently? Gerontologist. 1994;34:775-786.
19. Avoidable versus unavoidable pressure ulcers: what is the evidence? National Pressure Ulcer Advisory Panel/Conference. October 7, 1999. New York University-Division of Nursing Center for Continuing Education.
20. Brandeis GH, Morris JN, Nash DJ, Lipsitz LA. The epidemiology and natural history of pressure sores in elderly nursing home residents. JAMA. 1990;264:2905-2909.
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