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The prevention, treatment and liability of pressure ulcers in the nursing home.

Mrs. X, an 80-year-old woman with a history of insulin-dependent diabetes, high blood pressure, dementia, and peripheral neuropathy, was admitted to a nursing home for rehabilitation following repair of a fractured left hip. On admission she was assessed for pressure ulcer risk using the Braden Scale. For a Braden Score of 14 (moderate risk), the nursing staff initiated a plan of care to prevent the development of a pressure ulcer. This included placement of a pressure redistribution mattress on her bed and a cushion in her wheelchair. Three months later Mrs. X had completed rehabilitation. She could ambulate with a rolling walker and she transitioned to long term care. The following year, Mrs. X became more confused and her oral intake decreased; she lost 5 pounds. During a weekly skin assessment the nurse noticed a blister on her left heel, possibly caused by pressure to her heel from walking in a new pair of shoes or from lying in bed. The nurse documented the occurrence in the record and reported the blister, as well as the resident’s overall decline, to the resident’s daughter and to her attending physician. The physician ordered laboratory studies, including a urine culture and serum albumin, dietary supplements, a foam foot elevator, and a treatment plan for the blister. In spite of the interventions, Mrs. X continued to lose weight, her blood sugars became unstable, and her left heel blister worsened. The nurses documented the wound as a stage III pressure ulcer (PU). The staff continued conscientiously to provide wound care and entice Mrs. X to eat. She slowly improved, regained most of her lost weight, her blood sugars stabilized, and she became more alert. However, her left heel ulcer worsened without pain or sign of infection. Over the following several months Mrs. X’s physician adjusted the treatment plan for the ulcer, without improvement. Non-invasive arterial studies revealed a high-grade stenosis with almost complete blockage of the arteries from the knee to the left foot. Mrs. X was hospitalized. After two failed procedures aimed at improving arterial blood flow, an above-theknee amputation was necessary. Upon discharge from the hospital, she moved to another nursing home. The subsequent year Mrs. X’s family filed a lawsuit against the nursing home for $350,000 in damages. The complaint alleged that Mrs. X had suffered a belowthe-knee amputation caused by the “completely preventable and treatable pressure ulcer of her left heel.”