Bed Sores in Nursing Homes, Part 1

Pam: Barry, one of the most common types of cases you handle involving nursing homes are bed sore cases. Let me start by asking what are bed sores?

Barry: So there are a couple of different names for bed sores, and they're all the same thing, just different names. They're sometimes called decubitis ulcers, sometimes they're called pressure ulcers, sometimes they're called pressure sores, but in the end, what these are, are they are breakdowns in the skin, typically over the bony prominences. The most common places you see them are on your tailbone, buttocks, hips, on the heels, sometimes on the elbow or the back of head.

The term bed sore is one of these terms that's really sort of deceptive in terms of describing how serious it is. When people hear the term bed sore, in their mind's eye, they get this picture of something that's like a giant mosquito bite, and a lot of times, when people actually see what a bed sore is like for the first time, they're shocked because these are really kind of gruesome, horrible injuries to see and to endure.

Now, how bed sores occur is, essentially, because there is pressure that's applied between a stationary surface, typically it's a chair or a bed, and the bony prominences, like your hips or your pelvis, and what happens is, is when people don't get moved frequently enough, the tiny little blood vessels that supply the skin are pinched off and shut off and there's inadequate circulation to the outer layers of skin and they start to breakdown and die.

There are four stages of bed sores. They're rated 1 through 4, 1 is the least serious, 4 is the most serious.

A stage 1 bed sore is just the very outer layers of skin and what's called a non-blanchable area of skin. So, if you poke down on your hand and there's the little bit of whiteness that happens, and then it returns to your normal skin tone, that's blanching of skin. If you have a non-blanch-able area, what that means is, that you push down and that whiteness doesn't go away in a timely kind of way. That's a stage 1 bed sore and that's an indication that there is damage to the outer layers of the skin, the tiny little blood vessels that are supplying that are not working the way that they should.

Now, a stage 2 bed sore means that the outer layers of skin have been damaged and there's a tiny little bit of depth that's there, just the very outer layers of skin. A stage 3 bed sore involves additional depth, you're down into the subcutaneous tissues. A stage 4 bed sore involves exposed muscle or bone and it's one of those things that, when people see for the first time, they're absolutely shocked to see.

Pam: That's really awful, Barry. So are nursing homes under any obligation to prevent these?

Barry: Bed sores are a huge issue in the nursing home industry. The occurrence of bed sores in a nursing home is one of the quality of care indicators that the federal government tracks in terms of giving nursing homes their star rating on the Medicare Compare website. The higher that rate is, the lower their star rating is going to be.

Past that, there is a specific regulation that's in place regarding bed sores and it's actually a two part regulation. Part one of the regulation says that, when somebody comes into a nursing home without a bed sore, they shouldn't develop them unless it's clinically unavoidable. And clinically unavoidable is a very high standard for nursing homes to meet.

The second part of the regulation says that, once somebody gets a bed sore, if they come into the nursing home with a bed sore, they need to receive the necessary care, treatment, and services that are required to prevent infection and prevent new bed sores from developing.

Pam: Okay. So what are some of the things that place a nursing home resident at risk for developing bed sores?

Barry: In the end, there are really three main factors that are associated with the development of bed sores and that is immobility, incontinence, and poor nutritional status. Immobility is just what it sounds like. Somebody is not able to stand up and walk. Being able to get up and walk relieves pressure. They're not able to reposition themselves easily in a bed or chair. It means that they are going to be exposing those tiny little blood vessels to continuous pressure.

The second is incontinence and it's incontinence of both bowel and bladder. There are chemicals within urine that help breakdown the skin, besides making the skin wet and more susceptible to having skin breakdown. The same is true with feces.

The last factor that is a risk factor for developing bed sores is poor nutritional status. Protein is the building blocks of skin and there is a lab marker called your albumin level and if you have a low albumin level, that's an indication that you have low protein stores and you are more at risk for the development of pressure ulcers.

Pam: So what kinds of steps should be taken to prevent the development of pressure ulcers?

Barry: The main step, really, is pressure relief considering that bed sores are mainly caused by pressure. You're at work on improving somebody's mobility, their ability to stand, typically that's done through restorative nursing. If somebody is really, truly bed bound or chair bound, then the key to this is going to be a regular turning and repositioning schedule.

The other step that really has to be done on a regular basis is making sure that incontinent care is being provided. If somebody is not continent of bowel and bladder, they need to be changed, probably, after an episode of incontinence. That way, the skin is no longer exposed to the chemicals and to the moisture that's associated with urine or feces.

And then, last step in addressing the risk of developing pressure ulcers is nutritional management. Typically, this involves giving a nutritional supplement or providing additional ounces of protein in somebody's diet.

So these three steps, these are all things that need to be done day in, day out, shift to shift, and this is an area where the nursing home business model, the profit model, really tends to fail nursing home residents because you end up with staff that's stretched too thin to actually get all these things done that really need to be done on a day to day, shift to shift basis, and bed sores really are the cumulative result of not getting this kind of care.

Pam: So how do nursing homes go about trying to defend these claims?

Barry: Nursing homes really focus in on the co-morbidities. In other words, the health conditions that somebody had when they came in the door. Typically, it's cardiac issues, it might be diabetes, might be steroid usage. There are a whole number of things, but the bottom line on their defense is always that the development of the bed sores is due to the person being old and sick. My response to that is, you knew that they were old and sick when they came in the door. It was your obligation to provide the kind of care that they needed.

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