Litigation Management

Medical Information Management In Nursing Home Litigation

Pressure Ulcers (Part II of II)

Authors:	Elizabeth Juliano
	James Fell

Introduction

The previous issue of The M.I.M. Reporter introduced several elements of the nursing home medical record which should be reviewed as part of the preparation of the medical defense in a lawsuit involving a pressure ulcer. In this edition, the authors will further identify how the medical record and other documentation may impact strategic planning in these lawsuits.

Complete analysis of the nursing home pressure ulcer case requires more than a review of the evidence contained in the medical record. When preparing the case analysis, the reviewer should evaluate nursing home services actually delivered to the pressure ulcer plaintiff against benchmarks derived from peer-reviewed and professionally-accepted clinical standards of care. This article will present some of these standards and discuss their application in the pressure ulcer lawsuit.

Additional Elements of the Review

Federal requirements stipulate that nursing homes employ a Resident Assessment Instrument (RAI) to evaluate the comprehensive medical and functional status of each resident. Although core elements of the RAI are specified by the Department of Health and Human Services, individual States have the latitude to extend assessment provisions beyond the minimum requirements. Detailed information on the RAI is available in the Version 2.0 Manual, with instructions for its application, via the Internet at the Health Care Financing Administration (HCFA) web site, www.hcfa.gov/medicaid/mds20.

Because the RAI provides a standardized framework for assessment of the resident’s functional capacities and health status, it is often the source of some of the most valuable information in the pressure ulcer lawsuit. A complete RAI is comprised of the following:

- Minimum Data Set: The Minimum Data Set (MDS) consists of a core set of screening and assessment factors, plus coding categories and definitions, which form the basis of the comprehensive assessment of the resident. The Background Face Sheet of the MDS must be completed upon the resident’s admission to the nursing facility. While this abbreviated portion of the MDS provides a summary of the overall functional capacities of the resident, it typically will offer little direct information regarding the resident’s skin integrity.
  
  The Full Assessment Form of the MDS must be completed by the 14^th day of the resident’s admission, based on a retrospective analysis of the resident’s health status over the prior seven (7) days. Within the Full Assessment, several subsections provide information relevant to the pressure ulcer case. For example, Section G evaluates the resident’s mobility and level of nursing assistance required, which has predictive value in establishing risk for pressure-related injuries. Section H describes the resident’s continence status. This also has predictive value because pressure ulcer risk increases in skin areas which are kept continually moist from urine or stool. Section I lists diseases presently afflicting the resident. Certain disorders such as cerebrovascular accident (CVA or "stroke") and various musculoskeletal conditions can limit the resident’s capacity to shift body positions and thus relieve pressure-prone sites. Item 2 of Section I also notes the pre-existence of any wound infections.
  
  Section M appraises the resident’s skin condition. If present, skin ulcers are "staged" according to severity (see Part I of this series) and differentiated as to type of ulcer, either pressure or stasis. This information will prove especially important in lawsuits in which a pressure ulcer is alleged if in fact the lesion noted is a stasis ulcer. The etiology of a stasis ulcer is poor circulation, which is more related to resident’s predisposing anatomy and physiology, rather than negligent care. Additional valuable information contained in Section M details the resident’s pressure ulcer history, other skin problems and lesions, skin treatments, and foot problems and care.
  
  Section AD of the Face Sheet and Section R of the Full Assessment provide spaces for the signature of persons completing the evaluations, and most importantly, the Registered Nurse MDS Assessment Coordinator. Federal requirements specify that this latter professional must certify the assessment as complete. For nursing homes with limited RN personnel, this directive can be met by hiring an MDS nurse expressly to review and validate MDS assessments.
  
  Triggers and Resident Assessment Protocols: Triggers are "red flag" elements of the MDS which target specific medical risk management issues for the resident. The Resident Assessment Protocol (RAP) Summary, Section V, lists potential medical and functional problem areas for a given resident. For each "triggered" RAP, guidelines contained in Appendix C of the HCFA RAI Manual will define areas requiring further assessment, which then should be used in decision-making as staff develop the Nursing Care Plan (NCP). The Care Planning Decision column of the RAP Summary must be completed within seven (7) days of completing the RAI (MDS and RAP’s).
  
  A pressure ulcer RAP will be triggered if the MDS assessment reveals the presence of one or more of the following risk variables in the resident:
  - Current pressure ulcer,
  - Bed mobility problem,
  - Bedfast state,
  - Bowel incontinence,
  - Peripheral vascular disease,
  - History of previous pressure ulcer,
  - Skin desensitized to pain or pressure,
  - Daily trunk restraint.
  The pressure ulcer RAP advises that the resident be carefully evaluated if the MDS reveals one of the following risk-associated disorders:
  - Diabetes,
  - Alzheimer’s Disease,
  - Dementia,
  - Edema.
  Further notations in the pressure ulcer RAP state that administration of antidepressant, antianxiety, and hypnotic medications can contribute to reduced mobility and other problems, which can in turn contribute to pressure ulcer formation. The pressure ulcer RAP recommends that care providers review the resident’s medical condition, medications, and other risk factors to verify the appropriateness of the interventions defined in the care plan and if these specified interventions are actually being implemented.
  
  Quarterly Assessment: The Quarterly Assessment documents health status of the resident between comprehensive assessments. HCFA requirements stipulate that this type of review be completed no less frequently than once every three months. The 2.0 Manual notes that at a minimum, three (3) quarterly reviews and one (1) full assessment are required in each twelve (12) month period. Section M of the Quarterly Review includes assessment items relative to pressure ulcer evaluation. These parameters are similar to those found in the admission MDS.
  
  Annual and Comprehensive Reassessment: A complete Annual Reassessment is required within twelve months of the most recent full assessment. However, a Comprehensive Reassessment can also be initiated before this time if a major change occurs in the resident’s health status. In the case of pressure ulcers, the RAI 2.0 Manual notes that the emergence of a Stage II or greater pressure ulcer, when no Stage II or greater ulcers were previously in evidence, will necessitate a Comprehensive Reassessment.

A number of other documents in the medical record will contain information regarding pressure ulcer assessments and treatment:

- Interdisciplinary Team Meeting: The Interdisciplinary Team (IDT) meeting brings together health professionals representing medical, nursing, social, physical therapy, and other services to ensure that the resident is receiving coordinated, wholistic care. Notes and plans resulting from IDT meetings should be a component of the medical record. In the case involving a pressure ulcer, the IDT meeting should ensure that treatment and rehabilitation objectives are clearly formulated. Care planning should be reflective of concerns identified in the pressure ulcer RAP and should also take into account the input of the resident and family members.
  
  Nursing Care Plan: Pressure ulcer assessments derived from the MDS and RAP’s provide the basis for development of a nursing care plan to address this problem. Per federal requirements, this plan should be developed within seven (7) days after completion of the RAI assessment. Although review of medical records may reveal that the facility relied on standardized NCP’s, these plans still should be individualized to address the particular care requirements of a given pressure ulcer situation and resident. The resident’s care plan should reflect that it was reviewed and updated as necessary on each occasion that a RAI comprehensive assessment was completed.
  
  Treatment Records: Treatment records are used by nursing homes to record the delivery of routinely administered nursing care. These records typically take the form of sign-off sheets indicating when pressure ulcer assessment, cleansing, and dressing applications were dispensed. Treatment records may also document the provision of medical devices (i.e. special beds) for pressure ulcer care, which should be reconciled against other documentation in the medical record, such as pressure ulcer assessments in nursing notes.
  
  Turning Schedules: The medical record may contain documentation of a positioning and turning schedule for the resident, as well as validation of the extent to which this schedule was followed. The typical bedfast resident should be turned and repositioned in anatomically-correct placement every two (2) hours. ¹ Nursing notes may reflect variables which impacted adherence to the turning schedule. For instance, a resident may have been regularly turned by caregivers, but through his own actions may have favored the immediate return to one particular position that would predispose him to pressure ulcer development. Muscle contractures may also have limited the extent to which nursing staff could comfortably reposition a resident.
  
  Photographic Evidence: Some medical records may contain photographs documenting the deterioration or healing of the pressure ulcer. Such evidence is a useful, graphic supplement to the written medical record.
  
  Nursing Notes: Properly written nursing notes should not be repetitious of other standardized pressure ulcer assessments, but should contain information which complements these evaluations, such as when the nurse noted that the condition of a pressure ulcer changed and the physician was notified. Issues relating to patient compliance with pressure ulcer protocols may be documented, as in the situation where a resident refuses to accept a particular treatment, such as a dressing change. Nursing notes may reflect content of information communicated to family members and evidence of concern, or lack thereof, for the welfare of the resident and his problem with skin breakdown.
  
  Laboratory Reports and Medication Records: Because a pressure ulcer is an open skin wound, it will typically be colonized by common bacteria such as S. aureus or E. coli. It is important to note that colonization is not synonymous with the pathological state of infection. While wound cultures will almost always indicate the presence of bacteria, to properly ascertain if an actual infection is present, the complete medical picture must be evaluated. Elevation of the serum white blood cell count should be a cause of clinical concern, as is the onset of a febrile state. Documentation which reveals the pressure ulcer is draining material that smells and appears purulent is another such indication. Under these conditions, culturing ulcer drainage may reveal high bacterial colony counts, and in these cases antibiotic medications are indicated. Sensitivity tests performed on these cultures will indicate if the appropriate antibiotic was ordered by the physician or if the bacteria were resistant to the medication. Pressure ulcer infections that go untreated can develop into a cellulitis of soft or connective tissue, which can then lead to sepsis throughout the body.²
  
  Radiographic Reports: As an infected pressure ulcer deepens it may reach the point where the bones are involved and become infected. This osteomyelitis is a serious condition and is difficult to successfully treat due to the somewhat limited vascularity of bone tissue. In such cases, antibiotic therapy may extend four to six weeks. An unresolved osteomyelitis involving a leg may ultimately necessitate amputation of that extremity. Elderly residents may first be evaluated for osteomyelitis via a plain film x-ray, but this may or may not be sufficient. MRI and bone scanning provide a more definitive assessment.
  
  Severe pressure ulcers may extend much deeper into soft tissue than visual inspection of the skin reveals. In this "tip of the iceberg" situation, a deeply-infected sinus tract may be present. Ultrasound and a CT scan may be required for complete evaluation of these soft tissue cases.³
  
  Telephone Records: The medical record may contain telephone slips documenting occasions when nursing staff contacted the physician to report on deterioration of the resident with a pressure ulcer. Such entries evidence the timeliness of nursing assessments and interventions in these cases, as well as the physician response.
  
  Physical and Occupational Therapy Notes: Functional impairments elevate the risk of pressure ulcer development in nursing home residents, and concerns in these areas will be evaluated in ongoing physical and occupational therapy notes. Very often these notes are quite detailed and can be consulted as a cross-check of pressure ulcer assessments recorded in nursing notes.
  
  Nutritional Records: Nutrition and hydration play significant roles in prevention and treatment of pressure ulcers. Sections "J" of the MDS Full Assessment Form and "K" of the MDS Quarterly Assessment Form denote weight gain/loss and hydration status. Section "K" of the Full Assessment identifies nutritional problems presented by the resident’s condition. In addition, certain laboratory studies may provide evidence of a decreased nourishment status. For instance, a serum albumen level of less than 3.3 gm/dL points to problems with nutritional intake in the pressure ulcer resident.⁴ Intake and output (I&O) sheets contain documentation relating to a resident’s consumption of food and oral supplements, as well as oral and intravenous fluids. Dietary records also tabulate the amount and types of food ingested by the resident.
  
  Vital Signs: Graphics sheets chronicle trends in the resident’s temperature, pulse, respirations, and blood pressure, and should be reviewed in the pressure ulcer case. Bergstrom and Braden (1992) note that low diastolic blood pressure and increased body temperature will increase the risk for pressure ulcer development.⁵ As previously noted, once a pressure ulcer has actually developed, elevated temperature may signal the presence of an infectious process.

Sources of Other Documents

Billing Records list special items received by the resident for the prevention and treatment of pressure ulcers. Billing records are not a component of the typical medical record and must be acquired separately. Examples of billable medical devices for pressure ulcers are convoluted foam bed pads, sheepskin pads, protective heel pads, elbow protectors, alternating pressure mattresses, water mattresses, low-air-loss beds, and air-fluidized beds. Normal saline solution, povidone-iodine, hydrogen peroxide, gauze pads, hydrogel dressings, and hydrocolloid dressings are examples of materials which will be billed as part of a wound treatment program. Billing records can support a defense attorney’s contention that every reasonable nursing measure was implemented to prevent/treat the plaintiff’s pressure ulcer.

Nursing homes should have a Registered Nurse or equivalent individual designated as the infection control officer. Responsibilities of this position include the monitoring of community-acquired and nosocomial (institution-acquired) infections, and the subsequent analysis of trends in various classes of infections. These infection surveillance reports should be reviewed as part of case preparation in the pressure ulcer lawsuit to provide a perspective of the nursing home’s standards and management of infection prevention.

Trauma can contribute to the formation or exacerbation of skin breakdown. For example, skin may have been abraded during a resident’s fall, with subsequent poor healing and development of infection. This situation does not constitute a pressure ulcer case. When a patient event takes place, such as a fall, that constitutes a departure from the normal course of daily care, nursing home staff will complete an incident or accident report. This document is not a component of the resident’s medical record, but instead is a separate internal risk management report. Review of any incident reports written during the course of the plaintiff’s residence in the nursing home may bring clarity to the true etiology of the alleged "pressure ulcer."

Clinical Standards – Internal

The facility’s nursing policy and procedure manual should be obtained and reviewed before undertaking an evaluation of the resident’s medical record. In the case of a single facility, this document will be specific to that particular institution. On the other hand, a more generic, network-wide policy and procedure manual may be in place for a nursing home corporation. Policy and procedure manuals establish internal clinical practice benchmarks against which nursing care of the pressure ulcer patient should be evaluated. Defense strategy is enhanced when it can be verified through the medical record that nursing staff adhered to institutional guidelines for the prevention and treatment of pressure ulcers.

Nursing department orientation and training materials also contain information pertinent to in-house clinical standards. Objectives and protocols defined in these documents relative to pressure ulcer care identify institutional expectations for assessment, documentation, prevention, and treatment of skin breakdown. Training files of nursing staff may contain orientation "check off" sheets that document orientation and/or instructional mastery of these particular items. In addition, employee continuing education records will evidence the nursing home’s commitment to ongoing training of its personnel in pressure ulcer prevention and care. All these staff development records can be used to advantage by the defense attorney to refute allegations that care administered by poorly trained nursing staff resulted in a resident’s pressure ulcer.

Clinical Standards – External

There are other published clinical standards for the prevention, care, and treatment of pressure ulcers in addition to the ones discussed in this article. The web site of the National Guideline Clearinghouse™ (NGC), located at www.guidelines.gov, provides one such helpful resource. Sponsored by the Agency for Healthcare Research and Quality in partnership with the American Medical Association and the American Association of Health Plans, the NGC site enables one to easily search for published, evidence-based clinical practice guidelines in a wide variety of subject areas. A query for "pressure ulcer" yielded the following guidelines:

1. "Prevention of Pressure Ulcers," produced by the University of Iowa was adapted from the 1992 guidance on pressure ulcers published by the Agency for Health Care Policy and Research (AHCPR). Intended for use by nurses, this resource characterizes patients at risk for pressure ulcer development and defines interventions to prevent skin breakdown.⁶
2. "Treatment of Pressure Ulcers," developed by the University of Iowa was based upon 1992 and 1994 guidance of the AHCPR. Treatment protocols to promote healing of pressure ulcers are outlined, along with interventions that clinicians should avoid.⁷
3. "Pressure Sores," is published by the American Society of Plastic and Reconstructive Surgery (ASPRS). This guideline defines the parameters and diagnostic tests that a physician should consider when performing a history and physical examination in a pressure ulcer case. Operative and non-operative strategies for both the outpatient and inpatient setting are outlined.⁸
4. "Pressure Ulcers," authored by The American Medical Directors Association (AMDA), offers guidelines derived from those of the AHCPR and presents detailed clinical algorithms for the recognition, diagnosis, management, and monitoring of this condition.⁹
5. The "Pressure Ulcer Therapy Companion," released by the AMDA in 1999, addresses additional details of pressure ulcer management and monitoring not contained in "Pressure Ulcers."¹⁰

Survey Reports

Regulatory and certifying agencies can be an additional source of information relating to nursing homes and quality of care issues. Although such inspection reports will not address the specific situation of an individual resident, they do provide the attorney with a gauge of the quality of nursing care in a given facility. Nursing home inspection reports can be obtained from State survey agencies or from the nursing home itself. Deficiencies in the attainment of regulatory standards are cited in these reports, along with the facility’s corresponding plan of correction.

One on-line resource for portions of these reports is Nursing Home Compare. This is a searchable web site found at http://www.medicare.gov/nhcompare/home.asp and is provided as part of the Federal government’s Medicare information program. This website has the capability of generating similar statistics on a given nursing home and its population for such medical problems as urinary incontinence, behavioral symptoms, restricted joint motion, unplanned weight gain or loss, etc.

To illustrate the utility of this web site, suppose an Ohio nursing home is named in a pressure ulcer lawsuit. The defending attorney must determine if this case is an isolated situation or if conditions in the facility are such that the larger resident population is at special risk for pressure ulcer development. A search of Nursing Home Compare yields a graphic representation indicating that 10% of patients in the defendant nursing home have pressure ulcers, compared to the Ohio average of 6% and a national average of 7%. However, as the Nursing Home Compare web site indicates, this information must be carefully critiqued before drawing conclusions regarding quality of care in a given nursing home. In institutions where high percentages of residents are afflicted with pressure ulcers, substandard care may be an issue, or conversely, the home may have special expertise in care of pressure ulcer residents and may actually be a referral site for treatment of these patients.

One drawback of Nursing Home Compare is that this source only provides reports on nursing homes which are Medicare or Medicaid certified. For information on other elder care facilities and to obtain complete inspection reports, attorneys should contact the appropriate State survey agency. Addresses and phone numbers for these offices can be located at http://www.medicare.gov/Contacts/Home.asp.

Summary

This series of articles on medical information management for pressure ulcer litigation has revealed that a number of variables must be addressed in the analysis of these cases. Nursing home pressure ulcer claims must be first reviewed to determine if the case truly involves a pressure versus another type of skin ulceration not correlated with issues of nursing care neglect. Additionally, a comprehensive review should establish the degree to which skin breakdown may have occurred in the plaintiff before admission to the defendant nursing home, all predisposing medical factors, and the extent to which nursing and medical care deficiencies are implicated in pressure ulcer formation/exacerbation. Most importantly, analysis of the medical evidence must enumerate how pressure ulcer progression has impacted the overall physiologic and emotional integrity of the claimant.

Claimants may allege the development of other adverse medical conditions while residing in the long or short-term care environment. Litigation associated with these disorders can pose serious financial, certification/regulatory, and public relations threats for nursing homes. In future editions of The M.I.M. Reporter, the authors will examine the unique medical information management aspects of nursing home litigation related to resident falls, nosocomial pneumonias, malnutrition, and dehydration.

Note to our readers: If you missed Part I of this series and would like to obtain a free copy of this article, please contact the Editor of The M.I.M. Reporter at 440-484-2000.

¹ Merck Manual of Geriatrics. (online version) Chapter 14.

² Ibid.

³ Fauci AS, et al. Harrison’s Principles of Internal Medicine, 14^th Edition. New York: McGraw-Hill, 1998: 825-6.

⁴ Merck Manual of Geriatrics. (online version) Chapter 14.

⁵ Bergstrom N, Braden B. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc. 1992;40(8):757.

⁶ BA Folkedahl, RA Frantz, C Goode. Prevention of pressure ulcers. Iowa City: University of Iowa Gerontological Nursing Interventions Research Center, 1997.

⁷ BA Folkedahl, RA Frantz, C Goode. Treatment of pressure ulcers. Iowa City: University of Iowa Gerontological Nursing Intervetions Research Center, 1997.

⁸ American Society of Plastic and Reconstructive Surgeons Guidelines Committee (VL Lewis, lead author). Pressure sores. Arlington Heights, IL: American Society of Plastic and Reconstructive Surgery, 1996.

⁹ J Feinberg, J George, G Grossberg, J Johnson, L Lawhorne, S Levenson, J Ouslander, S Pettey, G Taler. Pressure ulcers. Columbia (MD): The American Medical Directors Association, 1996.

¹⁰ J Dimant, J Gruber, D Adams, N Bang, D Brickley, B Harrison, D Horton, V Reifsnyder, P Stevenson, G Taler, J Thompson. Pressure ulcer therapy companion. Columbia (MD): The American Medical Directors Association, 1999.

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