Legal Issues in the Care of Pressure Ulcer Patients - Medline

sttttttttttttsMy attorney sent a file box filled with medical recordsfor me to review. I was frustrated as I reviewed theserecords. Notes were handwritten, difficult to read andfragmented with different disciplines writing in varioussections. Very few notes were made in the commentsection of the nursing notes. Flow sheets were not completed.It was challenging to determine if the patientactually had been turned, cleansed and repositionedconsistently. Although the patient was incontinent ofstool, there were very few episodes of incontinencenoted. Even though I remembered that she was placedon a special mattress for pressure redistribution, I wasunable to determine this fact from the chart, despitethe fact that a special bed was ordered on day eight.The DepositionThe attorney for the plaintiff handed me the nurses’notes for the first seven days of the patient’shospitalization and asked me to read the BradenScore, the integumentary, neuromuscular section,turning/repositioning section of the flow sheet andthe nurses’ comment section. There was very littlecharted in any of the sections. The Braden Scoreshowed the patient to be at high risk for pressureulcer development. I was unable to find a plan ofcare in any of the files. Although the hospital hadjust implemented a new pressure ulcer program,none of the new forms or the pressure ulcer trendingwere filled out. The attorney had me go throughthe chart looking for documentation of instancesof patient non-adherence. I was stunned at the lackof documentation by both physicians and nursesabout her behavior, the skin and the pressure ulcerthroughout her hospitalization.The opposing counsel had me read my own chartingfor the times I had interacted with the patient andasked if the doctor had been informed consistentlyregarding the skin changes and wound managementof the pressure ulcer. I was embarrassed with myown charting and lack of information charted. Thephotographs taken throughout her hospitalizationwere not labeled properly and were out of sequence.There were no follow-up notes to indicate the patientor family received education about pressure ulcerprevention or treatment. There also was no dischargenote detailing the pressure ulcer other than the orderto continue negative therapy.Lessons LearnedSome of the common complaints registered againstnurses in a lawsuit are failure to follow a standardof care, failure to communicate, failure to assess andmonitor appropriately, failure to report significantfindings, failure to act as a patient advocate andfailure to document. That certainly applies in thiscase. Documentation is essential! Here are the mainlessons I learned from this experience:• On admission, it is important for the woundcare specialist to assess the patient’s skin andwound and write a detailed, initial, focusedassessment. If a wound is present on admission,document the wound profile.• Document the type of support surface thepatient is on or whenever a support systemchange is ordered.• Take a clear photograph of the wound accordingto your organization’s guidelines. For me, thatwould mean using a measurement label and ablack marking pen to clearly identify the patient’sname or initials, medical record number, dateand location of the wound on the photo.• Review and follow the guidelines relatedto skin and wound care.• Label and place the prevention protocolstanding orders and, if a wound is present,the wound and skin care treatment standingorders. Complete the required sections and sign.• Notify the physician regarding the skin/wound condition. Based on your findings,document if the wound is healable ornon-healable and document the interventionsfor prevention and treatment of the skin/wound.• Make sure you do a follow-up note.• Record in the discharge note the skinand wound status.• Remember the power of words. Payattention to “words not to use.”After a few months, the case was settled out of court in favor of the patient.I hope by my sharing my own story of doing a deposition, you will gain from my pain!sttttttttttttsLegal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers22