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Defending Severe Pressure Ulcer Malpractice Claims
January 13, 2023
Improper monitoring of physiological status
A 90-year-old man with dementia was transferred to the hospital from his senior living center with a fever, chills and increased respiratory effort. During his hospital stay, he was treated for pneumonia and developed deep tissue injuries (DTIs) of both his heels and coccyx. Redness in these areas was noted five days after admission as he was being transferred to the skilled nursing area of the hospital. A week later, upon discharge from the hospital back to his senior living center, the man’s heel wounds were noted to be purple fluid-filled blisters, and his coccyx had an open ulceration. The care team performed multiple dressing changes and debridement to these areas over the next several months before all areas healed.
His family filed a malpractice claim against the hospital, alleging improper monitoring and failure to prevent the pressure ulcers. The defense of the claim was hampered by insufficient and inconsistent documentation by the nursing team and their failure to follow the hospital’s care policy for patients at risk for developing pressure ulcers. The claim was closed with payment to the man and his family on behalf of the hospital.
Improper monitoring claims
Malpractice claims alleging improper monitoring of the physiological status of patients and senior living residents are frequent. Many of these claims involve deep tissue injuries (DTIs) which often evolve into severe pressure ulcers. Constellation analyzed recent claims involving pressure ulcers and found that these cases involved individuals who were deemed at high risk due to their illness or preexisting conditions.
“There is a misperception that all severe pressure ulcers are avoidable, when research has shown that the person’s illness or physical condition may predispose them to developing these problems despite frequent repositioning and good skin care,” says wound care expert Caroline Fife, MD. “It’s important to have a conversation with patients, senior living residents and their families about the physiological cause of DTIs and severe pressure ulcers in order to set appropriate expectations.”
Top contributing factors to severe pressure ulcer claims
Copyrighted by and used with permission of The Risk Management Foundation of the Harvard Medical Institutions Incorporated. All rights reserved.
Constellation is a member of the Candello community and participates in its national database.
Candello, a division of CRICO, the medical malpractice insurer for the Harvard affiliated medical institutions, is a national medical malpractice data collaborative representing one-third of U.S. malpractice claims.
The top factors contributing to these pressure ulcer malpractice claims include issues with the monitoring skills of the nursing care team, documentation problems, organizational policy not followed and/or breakdowns in communication among the care team regarding the patient or senior living resident’s condition.
Failure to follow policy and insufficient documentation predict malpractice claim losses
In their 2020 Annual Benchmarking Report, The Power to Predict: Leveraging Medical Malpractice Data to Reduce Patient Harm and Financial Loss, Candello research shows that the odds of a malpractice claim closing with a payment increased by 145% when the involved organization lacked a formal policy or an existing policy was not followed by the care team. Claims with absent, insufficient or inconsistent documentation had 90% higher odds of closing with payment than a malpractice claim without this factor.
Frequently, we’ll see organizations write care policies only to find that the care team is unable to operationalize these policies at the bedside due to unrealistic requirements. We call these ‘aspirational policies’,” says Monica Chadwick, Constellation Senior Risk Consultant. “Organizations should perform periodic medical record audits to ensure care team documentation meets the standards set forth in organizational policies.”
Five steps to mitigate severe pressure ulcer malpractice claims
Enhance team member assessment and monitoring skills with routine training using scenario-based learning modules.
Develop care policies that are realistic and evidence based.
Utilize structured communication processes and tools to enhance communication among the team regarding the patient or senior living resident’s condition.
Manage expectations of DTI/severe pressure ulcer development by using a shared decision-making approach, clearly communicating the risk of DTIs/severe pressure ulcers due to current illness or physical condition(s).
Hardwire documentation templates that prompt assessments and ensure consistent documentation among the care team. Periodically audit medical records to ensure compliance with documentation standards.
How Constellation can help: The HEAL Prepare Toolkit
Constellation’s HEAL Prepare Toolkit will help assess your team’s readiness to communicate following a pressure ulcer harm event like this one and help you get to best practices. The Toolkit includes assessments, best practices, sample tools and coaching. Start your journey by taking the HEAL Assessment, and then the Action Plan will guide you through the Toolkit’s four units: (1) culture, (2) event response, (3) communicating after harm events, and (4) moving forward. Sign in to ConstellationMutual.com to access the HEAL Prepare Toolkit found in Risk Resources.
Constellation’s HEAL program provides healing benefits for care teams and their organizations because we truly believe that what’s good for care teams is good for business.
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