Decubitus Ulcers
Decubitus ulcers or pressure ulcers can develop when somebody is left in the same position too long and contact is being made with a portion of their body and a surface. If their circulation is cut off by the pressure, a pressure sore or bed sore can develop. Often, individuals who are normally active, are admitted to a nursing home, and are unable to move on their own. Often, individuals suffer an injury, which requires them to have surgery, which then leads to a stay at a nursing home for rehabilitation. If, as a result of their surgery, they are unable to move on their own, the staff at the nursing home must turn and re-position them every two hours, to make sure that no one part of their body has pressure on it for too long of a period of time. If there is pressure on any area of the body for too long, then a pressure ulcer or decubitus ulcer or bed sire can begin to develop.
Decubitus ulcers or pressure ulcers are ranked in stages, Stage 1 through Stage 4.
A Stage 1 pressure ulcer does not show any skin breakage. It often appears as a reddened area. Stage 1 ulcers can be difficult to discern on people who have dark skin color. On people with lighter skin color, it usually appears as a reddened area.
A Stage 2 pressure ulcer or decubitus ulcer, is a superficial breakdown of the skin, and can show as a blister. The very top layer of the skin is known as the epidermis. The layer underneath that is known as the dermis. The layer underneath that is known as subcutaneous tissue. The layer underneath that is known as fascia. The layer underneath that is muscle. The layer underneath that is bone. A Stage 2 ulcer is a superficial break in the skin that only goes into the dermis layer.
A Stage 3 ulcer is a full-thickness skin break that goes into the subcutaneous tissue but does not go into the muscle or bone.
A Stage 4 pressure ulcer penetrates through the skin to deeper tissue and can actually go all the way to the bone.
Some decubitus ulcers or pressure ulcers are unstageable. Some decubitus ulcers or pressure ulcers have necrotic or dead tissue that is also called eschar. Often these wounds cannot be staged because the base of the wound cannot be seen so it is unknown how deep the wound goes.
Some nursing home residents develop moisture-associated skin damage. This is skin damage from repeated or sustained exposure to moisture. Sometimes, a resident who is incontinent, in other words, a resident who cannot control when they urinate or when they defecate, who is not being attended to on a regular basis, can develop moisture-associated skin damage. If they are left sitting in feces or urine for an extended period of time, they can develop a reddened area that can cause itching, burning, tenderness, and also a shallow skin breakdown. While it is not beneficial to leave a person with urine touching the skin for any extended period of time, feces are much more caustic and much more of a concern. This skin damage, is not unlike what a baby develops if a baby is not changed often and is left sitting in a wet diaper or a diaper that has feces in it. Sometimes this is referred to as adult incontinence dermatitis. This is a common problem in nursing homes where more than 50 percent of the elderly residents suffer from some kind of urinary or fecal incontinence. This can lead to itching, burning, redness, and other discomfort.
If your loved one is mentally incompetent because of dementia or some other difficulty, they may not be able to articulate their concerns with respect to skin irritation or pain. You must be particularly vigilant with mentally incompetent residents to make sure their needs are being met and they are not suffering skin breakdown.
In addition to decubitus ulcers or pressure ulcers, and skin damage caused by urine or feces, sometimes nursing home residents suffer skin tears from sheering or friction or blunt trauma. A resident who is being moved improperly, who is dragged across a sheet, can suffer a skin tear. A resident who is being transferred improperly from the bed to the wheelchair for example can suffer a skin tear or a blunt trauma bruise. If your loved one has such an injury you should talk with the staff and find out how such an injury occurred. You should also find out what they are doing to make sure that your loved one does not suffer additional injuries. Was the staff person involved educated, reprimanded, disciplined or fired? Was the rest of the staff educated? Was anything done? You should ask the Director of Nursing what was done to make sure your loved one is not injured in the future. If she does not have an answer, consider moving your loved one.
Pressure ulcers or decubitus ulcers often occur where the nursing home resident’s body makes contact with the bed or the chair. They often show up in the sacral area or on the buttocks where the person is laying down or seated. They often appear on the heels or the ankles. They sometimes appear on the resident’s elbows. They sometimes appear on the resident’s upper back. Sometimes there are even decubitus ulcers or pressure ulcers on a resident’s ears. It is very important, if someone you love is in a nursing home, and they are immobile, whether they are immobile for an extended period of time, or they are newly immobile because they suffered an injury which required surgery, or for some other reason, that you make sure that a plan is in place for them to be turned and re-positioned every two hours. This can help prevent decubitus ulcers or pressure ulcers.
According to the Code of Federal Regulations, the federal law that applies to all nursing homes in the United States, based on the comprehensive assessment of a resident, each and every nursing home in Ohio and elsewhere, must ensure that a resident who enters the nursing home without pressure sores does not develop pressure sores unless the individual’s critical condition demonstrates that they were unavoidable. Further, any resident having pressure sores, must receive necessary treatment and services, to promote healing, prevent infection, and prevent new sores from developing.
Infection is a serious problem with decubitus ulcers or pressure ulcers, especially when the skin is open. Our skin, our epidermis, is a system that is designed to protect our bodies. It is designed to keep infection out. The blood in our body is normally not exposed to outside elements including feces or urine. However, once a decubitus ulcer has advanced to at least a Stage 2 where the skin is open, that protective layer of skin is no longer in place to do its job and often an infection can result. Infections can be very serious for elderly nursing home residents. If an infection is left untreated it can be fatal for an elderly nursing home resident.
The worse a pressure ulcer gets, the less likely it is that pressure ulcer will ever heal. Many Stage 4 pressure ulcers never heal. Some require the nursing home resident to undergo surgery, which puts the resident at further risk of complications including death.
If your loved one enters the nursing home without decubitus ulcers, without pressure sores, they should not develop them at the nursing home. If they do develop a pressure sore or a decubitus ulcer at the nursing home, then you must immediately talk with the staff at the nursing home including the Administrator and Director of Nursing, and find out what the plan of care is for healing that ulcer. You should ask how often your loved one is being turned and re-positioned. You should ask how they keep track of turning and re-positioning. You should ask how often the records are checked to make sure each person at the nursing home is doing their job. Remember, your loved one must be turned or re-positioned every two hours, 24 hours a day, seven days a week. Pressure ulcers can form in the middle of the day or the middle of the night. Your loved one cannot be allowed to lay flat on their back for eights hours a night, without being at risk for developing a pressure sore on their buttocks or their back or their heels or elsewhere. It is very important that the resident be turned and re-positioned.
It is very important that once the ulcer has developed, that the wound receives appropriate treatment. The wound must be kept clean. Sometimes there is an advantage to bandaging the wound. Sometimes there is an advantage to leaving the wound open. Sometimes wounds heal quicker when they are dry and not bandaged. If the wound is supposed to be bandaged, the dressing or bandage should be changed on a regular basis. You should talk with the staff at the nursing home and find out how often the dressing or bandage is being changed. If you have a loved one in a nursing home who does suffer a wound, you should check the status of that wound often. Ask the nursing home when the bandage is changed and make sure you are there for the dressing change so you can see the wound. Sometimes the nursing home will refuse to remove the bandage to show you the wound, and as a result the wound might be getting worse and you don’t know it. The attorneys at The Dickson Firm have represented many clients who came to them after someone they loved suffered a horrific bedsore, and they did not know that the bedsore even existed until it was Stage 4 and infected.
If a decubitus ulcer is left untreated it will continue to grow. If a decubitus ulcer is under pressure, it will continue to grow. Once a person develops a decubitus ulcer it is imperative that the area where the ulcer exists does not have pressure put on it.
Signs that your loved one has an infected wound include the following:
- What is happening with the size of the wound? If the size of the wound is increasing, it may be because of an infection.
- Does the tissue around the wound feel warm?
- Does your loved one have a fever? If they have a fever this can be a sign that they have an infection.
- Does the wound have a bad smell. If the wound has a bad smell it may be because of the presence of bacteria.
- Does your loved one seem unusually lethargic. If they are, this could be because they’re fighting an infection.
There are numerous conditions which makes preventing decubitus ulcers and/or treating decubitus ulcers difficult if not impossible. Often people with diabetes develop decubitus ulcers and sometimes those decubitus ulcers cannot be prevented. Often people with peripheral vascular disease, which is a problem with the circulatory system which adversely affects blood flow, suffers ulcers or sores. These are not decubitus ulcers or pressure sores. These can be venous insufficiency ulcers or arterial insufficiency ulcers. Diabetics sometimes suffer diabetic or neuropathic ulcers. However, before you conclude that your loved one has developed a bed sore that could not have been prevented and cannot be healed, you should exhaust all the resources available to you. A wound care nurse should be consulted. A wound care doctor should be consulted. If necessary, your loved one should be hospitalized. Sometimes nursing homes do not want to send their residents to the hospital because if the resident at the hospital and not at the nursing home, the nursing home is not being paid for the resident’s care. You must not allow the nursing home’s financial concerns to keep your loved one from getting the appropriate care that they need. If necessary, demand that your loved one be sent to the hospital for evaluation. The worst thing that could happen is that they will go to the hospital, be evaluated, and a determination be made that the nursing home was giving them appropriate care. In that case, there will be no harm to the resident. The best thing that could happen is that your loved one could be sent to the hospital and a determination could be made that they did need additional treatment and they could get that additional treatment and avoid a bad outcome.
Decubitus ulcers can cause your loved ones, pain, suffering, and ultimately can be fatal. They must be taken seriously. If the nursing home is not doing all it can to prevent decubitus ulcers in your loved one and heal them, then you must advocate on their behalf.
One of the things to consider is whether or not your loved one has ever suffered a decubitus ulcer before. If your loved one lived at home and was active and was independent and didn’t have any skin breakdown, then, odds are, after their surgery, skin breakdown can be prevented at the nursing home with appropriate care. However, turning and re-positioning a nursing home resident every two hours means having enough staff so that every single resident who is at risk for skin breakdown can be turned and re-positioned every two hours. If the nursing home is not staffed properly, then this can lead to people not being turned and re-positioned. If you visit your loved one for more than three hours, you should see someone come in and turn and re-position them. Not only should they be turned and re-positioned in the bed, they should be re-positioned in a chair. They cannot sit in a chair in the same position for more than two hours. One of the things to ask is how many nurses and how many nurse’s aides are assigned to care for the residents at the nursing home. In other words, how many residents is each nurse responsible for? How many residents is each aide responsible for. Do the aides have time to turn and re-position each of their residents. This is important to find out.
If you suspect that someone you love is being neglected or abused in a nursing home, including developing decubitus ulcers or pressure ulcers, or in any other way, call The Dickson Firm and ask to speak with one of our nursing home attorneys. Ask for Blake Dickson or Ellen Hirshman. We would always be happy to talk with you and help you in any way that we can.