Pressure Ulcers are a growing target for attorneys bringing claims against hospitals, nursing homes, and doctors. Pressure ulcers are a universally recognized quality indicator, and since 2008 they are part of the Centers for Medicare and Medicaid Services (CMS) “no-pay list” for hospitals. This has brought increased scrutiny to pressure ulcers when they occur, and patients who get them, as well as their families, are expressing their dissatisfaction through lawsuits against caregivers. Physicians are frequently named in these actions, and this post will give tips on how doctors can avoid litigation or minimize risk once a lawsuit occurs.
Examine your patient and document the wound. Many physicians leave skin examination to the nurses, thinking that this is not their problem. This is a false assumption. All patients require skin assessment, and all wounds need proper documentation in the medical record. If you are unsure of the stage, write a detailed narrative description of what you see and/or draw a picture.
Educate families. When patients are at risk for pressure ulcers, this needs to be explained along with the interventions so families can participate if possible. Some pressure ulcers occur even with the best of care, and families need to be informed early when one occurs.
Don’t be adversarial. Stay away from the blame game. Never point fingers at nurses or colleagues when a pressure ulcer occurs as this can plant seeds that lead to litigation. This applies to written notes as well as verbal communications with colleagues and families.
Write explicit wound care orders. Wound care orders need to be specific and explicit. Each wound requires a separate dressing, and it is inappropriate to write “treat until healed.” Facility policies and formularies need to be considered when writing wound care orders.
Obtain early consultation with general or vascular surgery as indicated. Wounds with eschar often require debridement, and wounds of the lower extremities often require investigation of vascular status. Take early advantage of the expertise of your surgical colleagues when a wound occurs.
Understand tube feeding content and write detailed orders. Patients with wounds require additional calories, and tube feeding often needs upward adjustment. If a patient has a tube feeding, orders include type of product, rate, and number of hours administered. The physician should be aware of total calories administered per day. Read the nutritionist recommendations and ask questions of the calories appear inadequate. Additional laboratory studies such as serum albumen or pre-albumen may be indicated.
There is no agreement by experts that all pressure ulcers are avoidable, and as the population ages the number of people at risk will certainly increase. The best defense is proactive quality care for wounds when they occur.
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Determining the Avoidability of Pressure Ulcers
How CMS Views Pressure Ulcers in Hospitals
Optimizing a Hospital System to Prevent Pressure Ulcers
Pressure Ulcer Knowledge in Medical Residents: An Opportunity for Improvement
New Pocket Guide to Pressure Ulcers