Recently in Bedsores / Pressure Ulcers / Decubitus Ulcers Category

Pursuant to Maryland law, an assisted living program may not provide services to individuals who at the time of initial admission (as established by the initial assessment) would require: (1) more than intermittent nursing care; (2) treatment of stage 3 or stage 4 ulcers; (3) ventilator services; (4) skilled monitoring, testing, and aggressive adjustment of medications and treatments where there is the presence of, or risk for, a fluctuating acute condition; (5) monitoring of a chronic medical condition that is not controllable through readily available medications and treatments; or (6) treatment for a disease or condition which requires more than contact isolation.  See COMAR 10.07.14.22.I. 

This regulation requires assisted living facilities to request and obtain a resident specific waiver of care for a resident who sustains a stage 3 or stage 4 pressure ulcer while in the facility.

A pressure ulcer is a bed sore caused by unrelieved pressure on the skin that comes from lying in the same position too long and is associated with pain.    Assisted living residents may experience pressure from their bed and/or chair to certain points on their skin preventing the blood from flowing into those points.  Because the blood is not allowed to flow into those points, the skin, deprived of nutrients and oxygen, can become injured and susceptible to infection. 

Unfortunately, once a bed sore has progressed to stage 3 and stage 4, it is difficult to achieve healing and avoid painful and life-threatening complications.  These patients may develop osteomyelitis (infection of the bone) and sepsis ultimately resulting in death. 

Please feel free to contact the nursing home/assisted living neglect lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication error/prescription mistake, elder abuse or elder neglect.

According to Taber's Medical Dictionary, sepsis is defined as "the spread of an infection from its initial site to the bloodstream, initiating a systemic response that adversely affects blood flow to vital organs."  This condition can prove fatal and is a common cause of death in the elderly population including nursing home residents.

Sepsis can result from numerous conditions including bedsores (also known as pressure ulcers or decubitus ulcers).  A pressure ulcer is a bed sore caused by unrelieved pressure on the skin that comes from lying in the same position too long and is associated with pain.    Nursing home patients experience pressure from their bed and/or chair to certain points on their skin preventing the blood from flowing into those points.  Because the blood is not allowed to flow into those points, the skin, deprived of nutrients and oxygen, can become injured and susceptible to infection. 

Nursing home residents may be at risk for bedsores as a result of their underlying health problems and/or immobility issues.  The United States Centers for Disease Control and Prevention ("CDC") published a paper in February of 2009 entitled "Pressure Ulcers Among Nursing Home Residents: United States, 2004" concluding that "pressure ulcers are serious and common medical conditions in U.S. nursing homes, and remain an important public health problem." 

The standard of care applicable to nursing homes requires the nursing home staff to ensure that a resident entering the facility without pressure ulcers does not develop them unless the resident's clinical condition demonstrates that they were medically unavoidable.  The nursing home staff must also ensure that a resident having pressure ulcers receives necessary and proper wound care treatment and services to promote healing, prevent infection and prevent new ulcers from developing.  The nursing home staff must relieve pressure by turning and repositioning the resident at least every two hours while in bed and every hour while in a Geri-chair or wheelchair, maintain adequate nutrition and hydration, and prevent contractures of the extremities.

Unfortunately, once a bed sore has progressed to stage 3 and stage 4, it is difficult to achieve healing and avoid painful and life-threatening complications.  These patients may develop osteomyelitis (infection of the bone) and sepsis (blood infection) ultimately resulting in death. 

Oftentimes, the death certificate will list sepsis as the primary cause of death and include osteomyelitis and/or decubitus ulcers as contributing death factors.  In these circumstances, it may be advisable to consult with an attorney if you have reason to believe that the bedsores developed at the nursing home and were not timely diagnosed and/or treated.

Please feel free to contact the nursing home neglect attorneys at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication error/prescription mistake, elder abuse or elder neglect.

Under current Medicare guidelines, hospitals are no longer reimbursed for additional care resulting from pressure ulcers (also known as bed sores or decubitus ulcers) as the government has determined that development of bed sores at a hospital is a so-called "never event."  Additionally, hospitals cannot bill patients directly for such care.  The denial of reimbursement for such reasonably preventable treatment errors should provide hospitals with financial incentive to institute and implement appropriate patient safety measures geared toward preventing the development of bedsores. 

While there has been discussion about extending this policy to include long term care facilities including nursing homes and assisted living centers, nursing homes are not presently subject to these guidelines.  Nursing homes are therefore presently permitted to receive payment for care and treatment related to bedsores that develop in their facilities, while hospitals cannot.  This writer firmly believes that these Medicare "never events" guidelines should be extended to include nursing homes and other long term care facilities so that these facilities will have the same financial incentive as hospitals do to improve patient safety measures relating to preventing the development of bedsores.

Like hospital patients, nursing home residents are often at risk for developing bedsores as a result of their underlying medical problems and/or mobility issues.
 
A pressure sore/decubitus ulcer is a bedsore caused by unrelieved pressure on the skin that comes from lying in the same position too long and is associated with pain.  Patients experience pressure from their bed and/or chair to certain points on their skin preventing the blood from flowing into those points.  Because the blood is not allowed to flow into those points, the skin, deprived of nutrients and oxygen, can become injured and susceptible to infection.

A stage 1 ulcer presents as redness of the skin without a break in the skin and represents tissue injury that does not disappear when pressure is relieved.  A stage 1 ulcer is classified as nonblanchable erythema with intact skin.  Erythema is redness of the skin produced by congestion of the capillaries.  Erythema is the initial reactive hyperemia caused by pressure, and nonblanchable erythemia represents stage 1 pressure ulcer.

A stage 2 ulcer is characterized by partial-thickness skin loss, that is, the epidermis is interrupted as an abrasion, blister or shallow crater.

A stage 3 ulcer features full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend to, but not through, the underlying fascia.  The ulcer appears as a deep crater, with or without undermining of adjacent tissue. 

A stage 4 ulcer involves full-thickness skin loss (exposing bone or muscle) with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., a tendon or a joint capsule).

Once a bed sore has progressed to stage 3 and stage 4, it is difficult to achieve healing and avoid painful and potentially fatal complications.   With stage 3 or stage 4 pressure sores, the extent of the disease may not be evident because of covering necrotic material or eschar.  To establish the extent of the disease and promote healing, the necrotic material needs to be removed and surgical consultation may be required.  When ulcers develop over bony prominences, osteomyelitis is a potential complication.  Pressure ulcers are chronically contaminated wounds and the combination of bacteremia and pressure sores can be painful and life threatening.

Fortunately, as reflected by Medicare's "never event" guidelines, pressure ulcers may be entirely avoidable so long as proper care and preventative measures are instituted and implemented by the health care provider.  The time is right to extend these "never event" guidelines to include nursing homes and other long term care facilities.

Please feel free to contact the nursing home neglect attorneys at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication error/prescription mistake, elder abuse or elder neglect.

Gangrene is a serious, life-threatening medical condition requiring immediate medical attention that occurs when body tissue dies as a result of inadequate blood supply depriving the tissue of oxygen.  The affected area may become black and/or green, and give off a foul odor.

Gangrene can be caused by diseases that affect blood vessels (especially arteries) such as peripheral vascular disease.  Patients at nursing homes may also develop gangrene as a result of infected bedsores (also known as pressure sores or decubitus ulcers) that form on their sacrum, buttocks, heels or other areas. 

Once gangrene develops, the tissue death cannot be reversed.  In the early stages, gangrene may be treatable with antibiotics and/or surgical intervention.  Without timely medical intervention the patient may require amputation of the affected area.  Unfortunately, the development of gangrene may ultimately result in the death of the nursing home resident.

Gangrene develops over time and may be avoidable in nursing home residents so long as proper monitoring, proper care and proper preventative measures are instituted and implemented by the nursing home staff.

A sample Maryland Circuit Court Wrongful Death/Survivorship Complaint involving claims of negligence relating to development of gangrene follows:

COMPLAINT

Plaintiffs, [insert names], by their undersigned attorneys, hereby file this Complaint against Defendants, [insert names] and in support thereof, state as follows:

PARTIES AND JURISDICTION

 1.   At all times material to this case, Plaintiffs have been citizens and residents of the State of Maryland.  Plaintiffs, [insert names], are wrongful death beneficiaries in this action pursuant to Section 3-904(a) of the Courts and Judicial Proceedings Article of the Maryland Annotated Code.

 2. [Insert name] is the duly-appointed Personal Representative of the Estate of [insert name of Plaintiff].  The Register of Wills for [insert name of County] issued Letters of Administration to [insert name] on [insert date]. The Estate of [insert name of Plaintiff] is bringing this survival action pursuant to Section 7-401(x) of the Estates and Trusts Article of the Maryland Annotated Code.
 3. At all times material to this case, [insert names of Defendants] have been corporations engaging in the practice of medicine and rehabilitation services in Baltimore City, Maryland, and acting through actual and/or apparent agents, servants and/or employees.
 4. The venue for this claim is proper in Baltimore City, Maryland.  The amount in controversy exceeds Thirty Thousand Dollars ($30,000.00).

FACTS COMMON TO ALL COUNTS

 5. At all times mentioned and relevant herein, [insert names of Defendants] have owned, managed and/or operated a nursing and rehabilitation center known as [insert name of nursing home] located at [insert address] and have held themselves and their agents, servants and employees out to the general public as experienced, competent and capable providers of medical and rehabilitation services, and in such capacity owed a duty to [insert name of Plaintiff] and the Plaintiffs to render that degree of medical care and skill which is ordinarily rendered by those who devote special study and attention to the practice of medicine and rehabilitation services.
6. At all times mentioned and relevant herein, all of the individuals at [insert name of nursing home] who participated in the care provided to [insert name of Plaintiff] were acting on behalf of and within the scope of their employment and/or agency with [insert names of Defendants]. 
 7. On or about [insert date], [insert name of Plaintiff] was admitted to [insert name of nursing home] for short-term rehabilitation following a hospitalization at [insert name of hospital].  [Insert name of Plaintiff]'s doctors planned for her to return home following a brief rehabilitation at the [insert name of nursing home]. 
 8. The [insert name of nursing home] nursing staff initiated a Care Plan for [insert name of Plaintiff] that addressed the potential for altered peripheral tissue perfusion secondary to peripheral vascular disease.  The Care Plan goal was for [insert name of Plaintiff] to avoid complications of peripheral vascular disease. 
 9. Over the next few weeks, the nursing staff at [insert name of nursing home] failed to follow and implement the Care Plan for [insert name of Plaintiff]. 
 10. The records indicate that the staff at [insert name of nursing home] was aware that [insert name of Plaintiff] was at risk for the development of pressure ulcers, but the staff failed to create an appropriate Care Plan addressing the wounds on her heels.  Although there was a physician's order to elevate both of her lower extremities while she was in bed, according to the Treatment Record there were multiple failures by the staff to carry out this order.  Additionally, as documented in the records, a pressure relieving device was not provided for [insert name of Plaintiff]'s bed.
 11. On [insert date], it was documented in the records that [Plaintiff]'s family had complained that the wounds on her feet had a foul odor and blood was noted by the nurse who had changed the heel dressings.  Despite this change in [Plaintiff]'s condition, there is no evidence that a physician was notified.  On [insert date], [Plaintiff]'s right leg appeared swollen and she complained of pain.  An arterial Doppler study of the right lower extremity conducted revealed occlusion of the proximal and mid-superficial femoral arteries.
 12. [Plaintiff] was transferred to [insert name of hospital].  It was noted in the hospital records that [Plaintiff] had not been feeling well for the last few days and that she was found unresponsive at the nursing home.  [Plaintiff] was ultimately diagnosed with extensive gangrene of the right leg and passed away on [insert date].  The cause of death was sepsis due to leg gangrene.

COUNT I (Professional Negligence)

 13. The Plaintiffs incorporate all of the allegations contained in the above paragraphs as if those allegations are set forth in this Count.
 14. Defendants, individually and through their actual and/or apparent agents, servants and/or employees, owed [insert name of Plaintiff] a duty to exercise reasonable care in their treatment of her.
 15. Defendants, individually and through their actual and/or apparent agents, servants and/or employees, breached the above-described duty of care to [insert name of Plaintiff], thereby deviating from the applicable standards of care, and were otherwise negligent, careless and reckless in that they, among other things:
a. failed to timely diagnose and treat [insert name of Plaintiff]'s medical conditions;
b. failed to properly monitor and evaluate [insert name of Plaintiff]'s skin integrity;
c. failed to properly monitor and evaluate [insert name of Plaintiff] for compromised blood flow to her extremities;
d. failed to alert physicians regarding the changes in [insert name of Plaintiff]'s skin and underlying tissues;
e. failed to monitor and evaluate [insert name of Plaintiff]'s peripheral pulses and capillary refill times;
f. failed to provide adequate pressure relief for [insert name of Plaintiff]'s lower extremities;
g. failed to properly implement and revise [insert name of Plaintiff]'s care plan; and
h. were otherwise negligent and violated the applicable standards of care.
 16. As a direct and proximate result of the above-described deviations from the applicable standards of care and breaches of duty by Defendants, [insert name of Plaintiff] was caused to sustain serious, painful and permanent injuries to her body, including great physical and mental pain and suffering, and, ultimately, death.
 17. As a further direct and proximate result of the above-described deviations from the applicable standards of care and breaches of duty by Defendants, [insert name of Plaintiff], among other things, was forced to undergo medical treatment, and, as a result, was obliged to expend sums of money for medical, hospital and other care and treatment and was precluded from engaging in his normal and usual pursuits and activities, among other injuries and damages.
 18. Had Defendants followed the appropriate and applicable standards of care, [insert name of Plaintiff] would not have suffered the above-identified injuries, damages and death.
 19. The injuries and damages herein complained of were directly and proximately caused by the negligence and want of care of Defendants, with no negligence on the part of [insert name of Plaintiff] contributing thereto.

 WHEREFORE, the Plaintiffs request that a judgment be entered against the Defendants for compensatory damages in excess of Thirty Thousand Dollars ($30,000.00) and any other relief to which this Court finds them entitled.

COUNT II (Wrongful Death)

 20. The Plaintiffs incorporate all of the allegations contained in the above paragraphs as if those allegations are set forth in this Count.
 21. As a direct and proximate result of the Defendants' above-described negligence in causing the death of [insert name of Plaintiff], the Plaintiffs have sustained, among other things, pecuniary loss, mental anguish, emotional pain and suffering, loss of society, loss of companionship, loss of comfort, loss of protection, loss of parental care, loss of filial care, loss of attention, loss of advice, loss of counsel, loss of guidance and loss of education. 
 WHEREFORE, the Plaintiffs request that a judgment be entered against the Defendants for compensatory damages in excess of Thirty Thousand Dollars ($30,000.00) and any other relief to which this Court finds them entitled.

*  *  *

Please feel free to contact the nursing home neglect lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of the development of gangrene, bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication error/prescription mistake, elder abuse or elder neglect.

Elderly nursing home patients are at risk for developing bedsores (also known as pressure sores or decubitus ulcers).  Decubitus ulcers are bed sores caused by unrelieved pressure on the skin from lying or sitting in the same position too long and are associated with pain.   

Once a bed sore becomes infected and progresses to stage 3 and stage 4, it is difficult to achieve healing and avoid painful and life-threatening complications.  These individuals may develop sepsis (blood infection) and/or osteomyelitis (infection of the bone) requiring surgical wound debridement, and ultimately resulting in death.     

Fortunately, decubitus ulcers are entirely avoidable as long as proper care and preventative measures are instituted and carried out by the nursing home staff.  Under new Medicare guidelines, hospitals are no longer even reimbursed for additional care resulting from bed sores as the government has determined that development of bed sores at a hospital is a so-called "never event." 

Under Maryland law, when a nursing home resident dies as a result of nursing home negligence, two causes of action arise: (1) a wrongful death claim; and (2) a survivorship claim. 

In our nursing home bedsore cases, we routinely serve Corporate Designee Deposition Notices upon the Defendants along with the Complaint and other discovery requests at the outset of the case.  In this regard, Maryland Rule 2-412(c) and (d) requires nursing homes to produce documents (including medical records and policies and procedures) and to designate individuals to testify as to matters set forth in the deposition notice.  The testimony given will bind the nursing home on the subjects described. 

Our Corporate Designee Deposition Notices are targeted to obtain records and information concerning important issues including: (1) ensuring that the proper corporate entities have been named as Defendants; (2) ensuring that the healthcare providers at issue are employees or agents of the Defendants; (3) ensuring that information contained in medical records or other documents is accurate; (4) potential defense motions to transfer venue; (5) the treatment provided to the plaintiff; (6) the nursing home's policies and procedures concerning a variety of areas including wound prevention and wound care; and (7) potential nursing home staffing shortages.  These Corporate Designee Depositions also force the nursing homes and their lawyers to focus on and evaluate the circumstances of the case at an early stage as they have to identify and produce witnesses for deposition, and may help to facilitate early mediation or settlement.
 
A sample Corporate Designee Deposition Notice in a wrongful death/survivorship lawsuit involving claims of negligence relating to nursing home bed sores/pressure sores/decubitus ulcers follows:

NOTICE TO TAKE DEPOSITION

Pursuant to Maryland Rule 2 412(c) and (d), you are requested to do the following:
(a) designate one or more officers, directors, managing agents, or other persons who will testify on your behalf regarding the following matters known or reasonably available to the organization, and
(b) produce for inspection and copying at the deposition all documents or tangible things within your possession, custody or control regarding the following matters:

1. The corporate structure of [INSERT NAMES OF DEFENDANTS], and their parent corporations, subsidiaries, and affiliated entities from 2005 to the present.
2. The nature and scope of all operations and business activities of [INSERT NAMES OF DEFENDANTS] from 2005 to the present.
3. The corporate structure and scope of operations of all facilities owned, operated, managed, or supervised by [INSERT NAMES OF DEFENDANTS] from 2005 to the present.
4. The nature and scope of all advertising activities of [INSERT NAMES OF DEFENDANTS] within the City of Baltimore from 2005 to the present.
5. The nature and scope of all services, including but not limited to, nursing home, assisted living, in-patient and outpatient rehabilitation, hospice, and home health care services provided by [INSERT NAMES OF DEFENDANTS] and their parent corporations, subsidiaries, and affiliated entities, within the City of Baltimore from 2005 to the present.      
6. The care provided to [INSERT NAME OF PLAINTIFF] during his stay at [INSERT NAME OF NURSING HOME FACILITY] during the time period of [INSERT DATES OF ADMISSION], including but not limited to efforts to turn and reposition the patient, and monitor, prevent and treat decubitus ulcers.
7. The skin care and wound care, prevention and treatment provided to [INSERT NAME OF PLAINTIFF] at [INSERT NAME OF NURSING HOME FACILITY] from [INSERT DATES].
8. All skin evaluation practices and procedures in effect during [INSERT NAME OF PLAINTIFF]'s stay at [INSERT NAME OF NURSING HOME FACILITY].
9. All policies, practices, and procedures in effect during [INSERT NAME OF PLAINTIFF]'s stay at [INSERT NAME OF NURSING HOME FACILITY] pertaining to the prevention of decubitus ulcers/ pressure wounds.
10. All policies, practices, and procedures in effect during [INSERT NAME OF PLAINTIFF]'s stay at [INSERT NAME OF NURSING HOME FACILITY] pertaining to the prevention of decubitus ulcers/ pressure wounds via the use of specialty mattresses or beds.
11. All policies, practices, and procedures in effect during [INSERT NAME OF PLAINTIFF]'s stay at [INSERT NAME OF NURSING HOME FACILITY] pertaining to the care, treatment, and monitoring of decubitus ulcers/ pressure wounds.
12. All information and documents that discuss or pertain to any specialty mattresses or beds that were used in the care and treatment of [INSERT NAME OF PLAINTIFF]'s decubitus ulcers/ pressure wounds throughout her stay at [INSERT NAME OF NURSING HOME FACILITY].
14. All written manuals, guidelines, policies, or procedures in effect at [INSERT NAME OF NURSING HOME FACILITY] from 2005 through the present that discuss or in any way relate to the diagnosing, monitoring and/or treatment of pressure wounds and/or decubitus ulcers.
15. All information and documents that discuss or pertain to [INSERT NAME OF NURSING HOME FACILITY]'s  procedures, guidelines or policies in effect from 2005 through the present concerning the circumstances under which nurses and nursing assistants should consult with the patient's treating physician or other doctor regarding the patient's skin integrity or condition, including the development and progression of decubitus ulcers/ pressure wounds.
16. All policies, practices, and procedures in effect during [INSERT NAME OF PLAINTIFF]'s stay at [INSERT NAME OF NURSING HOME FACILITY] pertaining to the circumstances under which nurses and nurse practitioners should consult with the resident's treating physician or other physician regarding the patient's status and/or ongoing care needs at [INSERT NAME OF NURSING HOME FACILITY].
17. The identity of all individuals who provided care to [INSERT NAME OF PLAINTIFF]'s during his stay at [INSERT NAME OF NURSING HOME FACILITY] during the time period of [INSERT DATES OF ADMISSION] including but not limited to efforts to monitor, prevent and treat decubitus ulcers.
18. All policies, practices, and procedures in effect during [INSERT NAME OF PLAINTIFF]'s stay at [INSERT NAME OF NURSING HOME FACILITY] pertaining to incident reporting.
19. Information concerning and copies of all incident reports generated by Defendants and their agents or employees pertaining to the care provided to [INSERT NAME OF PLAINTIFF] during his stay at [INSERT NAME OF NURSING HOME FACILITY].
20. All policies, practices, and procedures in effect during [INSERT NAME OF PLAINTIFF]'s stay at [INSERT NAME OF NURSING HOME FACILITY pertaining to or relating to documenting a resident's medical records.
21. Information concerning and copies of all inspection reports or evaluations pertaining to the care provided to [INSERT NAME OF PLAINTIFF] during his stay at [INSERT NAME OF NURSING HOME FACILITY] generated by any federal or state government agencies (including but not limited to Adult Protective Services) that regulated or monitored [INSERT NAME OF NURSING HOME FACILITY].
22. Information regarding staffing levels, staffing sheets and staffing shortages at [INSERT NAME OF NURSING HOME FACILITY] during the time period during which [INSERT NAME OF PLAINTIFF] resided at [INSERT NAME OF NURSING HOME FACILITY].

* * *

Please feel free to contact the nursing home neglect lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication error/prescription mistake, elder abuse or elder neglect.

Non-ambulatory patients residing in nursing homes are at risk of developing pressure sores on their heel and ankle areas as a result of unrelieved pressure and friction.

Once these sores develop, it can be difficult to achieve healing and avoid potentially painful and fatal complications including sepsis (blood infection), osteomyelitis (bone infection), amputation, surgical wound debridement and even ultimately death.

It is therefore critical that nursing homes develop and implement wound prevention care plans and perform risk assessments at the time of admission.  In addition to daily monitoring and regular skin assessments, the nursing home staff must ensure that pressure and friction in the heel and ankle areas are reduced and relieved.  This may be accomplished as simply as through the use of pillows to offload the heels.  The nursing home staff must, however, be on the lookout for patient movement that may displace the pillow.  Other preventative measures include heel protectors, boots and pressure relieving mattresses.  Heel protectors may help to provide continuous pressure relief, and also act to minimize friction and shear on feet, ankles and heels. 

Families must be advocates for their loved ones and they should be on alert for these issues and regularly visit the nursing home resident and inspect their skin.  Families should also discuss preventative heel ulcer care with the nursing home staff.  As the saying goes, "the squeaky wheel gets the grease."

In our practice, we have seen the tragic results of the failure of nursing homes to implement effective and proper heel pressure ulcer prevention protocols.  In one situation, a vulnerable, mentally challenged individual was admitted to the nursing home with no skin breakdown for short-term rehabilitation services.  He had previously resided in a group home environment and was able to participate in an adult day program.  The plan was for him to return to his previous living arrangements and level of functioning upon his discharge from the nursing home.    During his stay at the nursing home, he did not receive visits from family members.  He was not provided with heel ulcer preventative care and, unfortunately, developed a heel wound that became infected and necrotic, and progressed to stage 4.  He went on to develop severe osteomyelitis of his heel.  In an effort to prevent the potentially fatal spread of osteomyelitis, doctors performed an above-the-knee amputation of his leg.  Sadly, this mentally challenged individual became bed-ridden, requiring permanent nursing home care and never returned to his previous level of functioning.

The good news is that heel pressure ulcers are entirely avoidable so long as proper care and preventative measures are instituted and implemented by the nursing home.  Under new Medicare guidelines, hospitals are no longer even reimbursed for additional care resulting from pressure ulcers as the government has determined that development of bed sores at a hospital is a so-called "never event."

Please feel free to contact the nursing home neglect attorneys at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication error/prescription mistake, elder abuse or elder neglect.

We frequently speak with families who wish to have potential nursing home negligence cases investigated while their family member or loved one simultaneously continues to reside in the target nursing home.  A typical scenario involves a nursing home resident who develops bedsores (also known as pressure sores or decubitus ulcers) during their stay at the nursing home.  The family eventually learns of the wounds and become frustrated as they continually find that their loved one: (1) has soiled themselves, and is dirty and not receiving adequate hygiene care; (2) has not been repositioned or turned; (3) is not receiving adequate hydration and nutrition; (3) is being left in a wheelchair or a Geri-chair without being repositioned for long periods of time; and/or (4) is not receiving regular wound care or medical attention.  The family complains to the nursing home staff regarding these issues, but their complaints are ignored.  The resident's bedsores continue to get worse, become infected and progress to stage 3 and then stage 4.  The resident is in and out of the hospital for wound care, wound debridement and treatment of osteomyelitis (bone infection) and sepsis (blood infection), and then transferred back to the nursing home.

We counsel families faced with these difficult circumstances to focus on the health and immediate well-being  and safety of their loved one.  Putting aside the merits of any potential lawsuit, a family considering suing a nursing home has obviously lost complete confidence in the nursing home's ability to care for their loved one.  As such, in a perfect world, the family should try to locate alternative care arrangements and have the resident transferred as soon as possible.  Everyone knows, however, that the world is far from perfect and that it can be extremely challenging to locate alternative care for many reasons including health insurance coverage issues, Medicare or Medicaid coverage issues, and/or the location of the facility.

In those circumstances where it is not feasible to move the patient, the family should be very careful that the nursing home does not become aware that a potential lawsuit is being investigated so that the patient's care is not compromised.  In these circumstances, our law firm may request medical records from outside hospitals and wound care centers in order to obtain additional information regarding the patient's condition and prognosis.  Based upon the information contained in the medical records, our firm's lawyers can help further counsel the family through this difficult situation in a manner that protects the resident from potential harm.  In the right circumstances, the family may also be directed to request medical records from the nursing home in order to help further facilitate the investigation. 

At the end of the day, these are very difficult issues and each circumstance must be evaluated and treated on a case-by-case basis.  The first concern must always be the health, safety and well-being of the nursing home resident.  The potential lawsuit is secondary and appropriate steps should be taken to ensure that the nursing home resident's health and safety are not jeopardized. 

Please feel free to contact the nursing home neglect lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication administration error/prescription mistake, elder abuse or elder neglect.

It can be difficult for Plaintiffs' attorneys to obtain timely discovery responses from Defendants in nursing home negligence cases.  It is not uncommon for months to elapse before Plaintiffs' counsel is able to even receive responses to written discovery and documents requests from the nursing home's lawyers. 

Maryland Rule 2-424, entitled "Admission of acts and genuineness of documents," provides Plaintiffs' lawyers with a powerful discovery tool that can help streamline the issues in the case in the early phases of litigation.  This Rule requires a party to admit or deny the truth of matters of fact set forth in separate requests for admission.  Importantly, a party must file responses to requests for admission of facts within thirty (30) days or the request shall be deemed admitted.  See Maryland Rule 2-424(b).  Nursing home defendants are therefore forced to take a position on various factual issues at the outset of the case before their attorneys and in-house risk managers have an opportunity to fully evaluate the issues.  In the event that defense counsel does not file timely responses, the value of the case can potentially increase. 

Our firm regularly serves Defendant nursing homes with detailed Requests for Admission of Facts along with the Complaint and initial pleadings in all of our nursing home neglect cases.  These requests cover a range of important topics such as: (1) ensuring that the proper corporate entities have been named as Defendants; (2) ensuring that the healthcare providers at issue are employees or agents of the Defendants; and (3) ensuring that information contained in medical records or other documents is accurate.  Detailed requests for admission of facts also force defense lawyers to focus on and evaluate the factual circumstances of the case at an early stage and may help to facilitate early mediation or settlement.

A sample set of Requests for Admission of Facts in a nursing home neglect bedsore/pressure sore/decubitus ulcer wrongful death lawsuit follows:

1. [Insert name of defendant] owns [insert name of nursing home facility].
2. [Insert name of defendant] operates [insert name of nursing home facility].
3. [Insert name of defendant] owned [insert name of nursing home facility] during the time period of [insert time period at issue in case].
4. [Insert name of defendant] operated [insert name of nursing home facility] during the time period of [insert time period at issue in case].
5. All of the individuals at [insert name of nursing home facility] who participated in the care provided to Plaintiff during his stay in [insert dates] as alleged in the Complaint were acting on behalf of and within the scope of their employment and/or agency with [insert name of Defendant].
6. On or about [insert date], Plaintiff was transferred to [insert name of nursing home facility] for short-term rehabilitation.
7. At the time of his admission to [insert name of nursing home facility], Plaintiff was examined by the admitting nurse who noted that his skin integrity was intact with no  skin breakdown, wounds or pressure ulcers.
8. At the time of his admission to [insert name of nursing home facility], Plaintiff was examined by the admitting nurse and noted to have no pressure wounds or decubitus ulcers on his sacrum.
9. At the time of his admission to [insert name of nursing home facility], Plaintiff was examined by the admitting nurse and noted to have no pressure wounds or decubitus ulcers on his sacrum or elsewhere on his body.
10. Around the time of Plaintiff's admission to [insert name of nursing home facility] a nurse completed a Braden scale for Plaintiff indicating that he was at mild risk for developing future pressure wounds or decubitus ulcers.
11. Physician orders at the time of admission to [insert name of nursing home facility] called for the nursing staff to reposition and turn Plaintiff every two hours and perform a full body inspection every week.
12. Over the next several months, [insert name of nursing home facility] failed to reposition Plaintiff every two hours and/or perform a full body inspection every week, as ordered by his physicians.
13. Over the next few months, the family found Plaintiff in soiled undergarments that had not been changed for long periods of time. 
14. On or about [insert date], nurses at [insert name of nursing home facility] documented that [Plaintiff] was suffering from a stage II sacral decubitus ulcer.
15. On or about [insert date], nurses at [insert name of nursing home facility] documented that [Plaintiff] was suffering from a stage III decubitus ulcer on his buttocks.
16. Plaintiff's sacral decubitus ulcer subsequently grew larger and became infected.
17. Plaintiff developed additional decubitus ulcers on his left buttocks and left heel.
18. Plaintiff was not assessed by a dietician at [insert name of nursing home facility].
19. Plaintiff was evaluated by the wound care team at [insert name of hospital] and diagnosed with a stage IV sacral decubitus ulcer.
20. Plaintiff was evaluated by the wound care team at [insert name of hospital] and diagnosed with a stage IV sacral decubitus ulcer with purulent drainage, necrosis, and deep tunneling.
21. Hospital records dated [insert date] indicate that doctors advised Plaintiff's family that his sacral decubitus would likely never heal and would require chronic care.
22. Plaintiff was ultimately discharged from [insert name of hospital] on [insert date] and transferred to [insert name of facilty].
23. Over the next six months, Plaintiff continued to suffer from his stage IV sacral ulcer and related complications.
24. Over the next six months, Plaintiff continued to suffer from his stage IV sacral ulcer and related complications until he ultimately succumbed to these conditions on [insert date].
25.  The Death Certificate lists the cause of death as sepsis due to a sacral decubitus ulcer with osteomyelitis.
26. Defendant failed to take reasonable and appropriate measures to maintain Plaintiff's skin integrity, which resulted in the development of multiple decubitus ulcers.
27. Defendant failed to ensure that Plaintiff received adequate wound care, as well as the diet and nutrition necessary for wound prevention and healing.
28. Defendant failed to adequately and timely assess, diagnose, and treat Plaintiff's pressure wounds and skin breakdown.

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Please feel free to contact the nursing home neglect lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication administration error/prescription mistake, elder abuse or elder neglect.

Elderly nursing home patients are at risk for developing bedsores (also known as pressure sores or decubitus ulcers).  Decubitus ulcers are bed sores caused by unrelieved pressure on the skin from lying or sitting in the same position too long and are associated with pain.   

Unfortunately, once a bed sore progresses to stage 3 and stage 4 and becomes infected, it is difficult to achieve healing and avoid painful and life-threatening complications.  These individuals may develop osteomyelitis (infection of the bone) and sepsis (blood infection) ultimately resulting in death.     

The good news is that decubitus ulcers are entirely avoidable as long as proper care and preventative measures are instituted and carried out by the nursing home staff.  Under new Medicare guidelines, hospitals are no longer even reimbursed for additional care resulting from bed sores as the government has determined that development of bed sores at a hospital is a so-called "never event."  Unfortunately, many nursing homes fail to provide the necessary and required preventative care, and decubitus ulcers/bedsores remain a serious and common medical problem in nursing homes in this Country. 

Under Maryland law, a nursing home negligence lawsuit is subject to the requirements of the Maryland Health Care Malpractice Claims Statute contained in Section 3-2A-01 et seq. of the Courts and Judicial Proceedings Article of the Maryland Annotated Code.  This statute, among other things, requires Plaintiffs to file a Certificate of Merit and Report from a qualified expert attesting to departures from standards of care proximately resulting and causing the alleged injury.  Creative defense attorneys have made numerous technical challenges regarding Maryland's certificate of merit requirements that have been the subject of several reported Maryland appellate cases and further legislative intervention.  It is therefore crucial that attorneys handling Maryland nursing home negligence cases be familiar with these ever changing certificate of merit requirements in order to avoid potential pitfalls that could ultimately result in the dismissal of meritorious cases. 

A sample Maryland Certificate of Merit and Expert Report involving claims of negligence relating to nursing home bed sores/pressure sores/decubitus ulcers follows:

CERTIFICATE OF MERIT OF [INSERT EXPERT'S NAME]

 I HEREBY CERTIFY and acknowledge that I have reviewed medical records and other documentation pertaining to the facts and circumstances in the above-captioned case.
 I hereby certify and acknowledge that there have been violations of the standards of care committed by [insert names of Defendants], and their respective agents and employees whose identities are contained in the medical records, which have directly and proximately resulted in damages and injuries to the Claimants.
 [Insert names of Defendants], and their respective agents and employees, breached the applicable standards of care in their treatment of [insert name of Plaintiff] and thereby caused the death of [insert name of Plaintiff] and damages and injuries to Claimants, in that they, among other things:
a. failed to adequately and timely diagnose and treat [insert name]'s medical conditions;
b. failed to take reasonable measures to maintain [insert name]'s skin integrity resulting in the development of threatening decubitus ulcers;
c. failed to ensure that [insert name] received adequate wound care, as well as diet and nutrition necessary for wound prevention and healing; 
d. failed to adequately and timely assess, diagnose, and treat [insert name]'s decubitus ulcers and skin breakdown; and
e. were otherwise negligent and violated the applicable standards of care.
 I certify that within the last five years I have been actively engaged in clinical practice, consultation relating to clinical practice, and the teaching of medical residents and nurses, with respect to the care and treatment of nursing home patients and the prevention and treatment of decubitus ulcers.
 I further acknowledge that less than 20% of my annual professional time directly involves testimony in personal injury claims.

_____________________                                         
[Signature line]

REPORT

 I am board-certified in geriatrics and am a Professor of Surgery at [insert name of medical school].  I have served on the editorial board of several professional journals pertaining to wound care, including [insert names of journals].
 This is to acknowledge that after my review of medical records and other documentation pertaining to the facts and circumstances in the above-referenced case, I have concluded to a reasonable degree of medical probability that [insert names of Defendants], and their respective agents and employees whose identities are contained in the medical records, breached the applicable standards of care in their treatment of [insert name of Plaintiff], in that they, failed to adequately and timely diagnose and treat [insert name of Plaintiff]'s medical conditions; failed to take reasonable measures to maintain [insert name of Plaintiff]'s skin integrity, which resulted in the development of life-threatening decubitus ulcers; failed to ensure that [insert name of Plaintiff] received adequate wound care, as well as diet and nutrition necessary for wound prevention and healing; and failed to adequately and timely assess, diagnose, and treat [insert name of Plaintiff]'s pressure wounds and skin breakdown.  I have further concluded that the above-described deviations from the standard of care were the proximate and substantial cause of [insert name of Plaintiff]'s death due to a sacral decubitus ulcer with associated osteomyelitis and sepsis.
 Accordingly, I have concluded that the case to be filed before the Health Care Alternative Dispute Resolution Office of Maryland is meritorious.
 This report is not, nor is it intended to be, an exhaustive description of all opinions and conclusions and their bases.  My opinions regarding the health care providers, and departure from the applicable standards of care, may be modified and/or supplemented upon review of additional information and/or documents.
 Finally, less than 20% of my annual professional time involves testimony in personal injury claims.

_________________        
[Signature line]

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Please feel free to contact the nursing home neglect lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication administration error/prescription mistake, elder abuse or elder neglect.