Allegation
The estate of an 80 YOF alleged that the rehabilitation facility failed to assess, monitor, and document skin integrity, nutritional intake, and repositioning practices, resulting in the development and progression of pressure ulcers, infection, and subsequent death.
Case Details
An 80 YOF was admitted to a rehabilitation facility following hospitalization for weakness and deconditioning. Her plan of care included physical therapy, nutritional monitoring, and nursing support for mobility and safety. The resident had comorbid conditions, including diabetes and mild cognitive decline, and required significant assistance with activities of daily living.
During the 15-day stay, nursing documentation showed inconsistent entries related to repositioning, skin assessment, and nutritional intake. The electronic record contained generic care-plan statements but lacked individualized interventions for skin integrity or evidence of resident and staff education on turning schedules. Progress notes reflected minimal reassessment of risk factors, and interdisciplinary communication about the resident’s declining condition was limited.
By the second week of admission, the resident developed pressure ulcers on the right heel and posterior leg, which worsened despite wound care. She was transferred to an acute-care hospital for surgical debridement. During that hospitalization, she was also diagnosed with a urinary tract infection. Her condition deteriorated, and she died two months later from complications of sepsis.
Around the same time, the facility underwent three state surveys, all citing deficiencies in skin-integrity management and documentation. Findings mirrored those in this case, noting a lack of preventive protocols, inconsistent recordkeeping, and poor staff training on pressure-ulcer prevention.
Expert Testimony
The plaintiff’s nursing expert testified that the standard of care required consistent assessment and documentation of skin condition, turning and repositioning every two hours, and nutritional intake monitoring—all of which were lacking. The expert noted that the care plan failed to reflect individualized risk-based interventions and that nursing staff did not document preventive measures or timely physician notification of skin changes.
The defense expert acknowledged gaps in documentation but suggested that care was likely provided, albeit poorly recorded. However, the absence of documentation left no defensible evidence that appropriate interventions were performed. The expert further noted that the facility’s protocol was outdated and lacked reference to current standards of care.
Due to the state survey citations and documentation failures, the defense determined the case would be difficult to defend successfully.
Resolution
The case was settled pre-trial following significant regulatory findings supporting the allegations. The settlement amount was undisclosed.
Risk Reduction Strategies
Strengthen Documentation and Care Planning
- Implement electronic documentation prompts or checklists for repositioning, nutrition, and pain management entries each shift.
- Require interdisciplinary review and updating of care plans when risk scores change or new wounds develop.
- Conduct monthly documentation audits with performance feedback to staff.
Standardize Pressure Ulcer Prevention Protocols
- Adopt an updated skin integrity protocol based on current guidelines.
- Use a validated risk assessment tool (e.g., Braden Scale) at admission and weekly thereafter.
- Implement automatic wound-care consults for new or worsening ulcers.
- Ensure adequate access to pressure-relieving devices and maintain logs verifying usage.
Staff Education and Competency Validation
- Provide annual competency-based education on skin assessment, repositioning techniques, and documentation standards.
- Include case-based simulations illustrating the consequences of poor documentation.
Leadership Oversight and Quality Monitoring
- Establish a Skin Integrity Committee to review wound trends and documentation compliance.
- Track pressure-injury rates, care-plan compliance, and audit results in quality dashboards.
- Conduct root cause analyses on any facility-acquired pressure injuries, ensuring lessons are communicated facility-wide.
Conclusion
Thorough documentation, individualized care planning, and ongoing staff training remain critical to both resident safety and legal defensibility. Consistent application of evidence-based pressure-ulcer prevention protocols and leadership oversight can help reduce risk exposure, improve regulatory compliance, and enhance resident outcomes. Although the resident likely received some level of care, the absence of timely and detailed documentation rendered the facility unable to demonstrate compliance with accepted standards.
