Untreated Decubitus Ulcer Leads To Sepsis and Death

Pt was an 80 year old woman with a past medical history of spinal stenosis, hypertension, atrial fibrillation, hyperlipidemia, chronic low back pain, hypothyroidism, heart murmur and macular degeneration.

She was admitted to a rehab center on March 22, 2007 after a brief hospitalization that determined back surgery would not be appropriate.

The admission notes reveal that she was alert and oriented and the plan was short term rehabilitation and then a return home with services.

On March 26, 2007, her daughter visited her and found that she had been sitting in a wheelchair from 8:30 a.m. to 5:30 P.M. The daughter also noted that she was cold and wet from urine and crying. On March 27, 2007, another daughter found her the same way and complained to the nurse.

On March 30, 2007, the daughter removed her mother’s pants so that she could use a bedpan. At that point the daughter noticed a large redspot on her tailbone and immediately reported it to the nurse.

Not withstanding, pt remained in a wheelchair. Apparently, no doctor examined the sore until April 10, 2007 when a nurse looked at it. From that point forward, the sore was was cleaned and dressed, but by April 19, 2007, she was found to have more bedsores near the original one as well as a large sore on her elbow.

She was examined on April 19, 2007 by a doctor who reported, “She presents with a 7 cm wide X 6.5 cm long X 6 cm deep stage III wound, full of necrotic skin and fat. This is flanked by 6 cm X 3 cm stage II ulcer and a diffuse outbreak of yeast surrounding the entire area. She also had a problem being treated for Clostridium difficile. The entire area was sharply debrided and remains at stage III without any tunneling.”

By April 21, 2007, the sore on her rear end became so bad that she had to be taken to a hospital. The history & physical examination note states: “Pt is an 80 year old woman with past medical history significant for hypertension, scoliosis and recent onset gait problem and lower extremity weakness which has been under workup and treatment, presented 4 days history of drowsiness and decreased p.o. intake. Patient has been recently diagnosed with a decubitus ulcer.”

She died on April 25, 2007. On the death certificate, the immediate cause of death was repiratory failue 20 minutes duration, cardiac arrest 15 minutes with an underying cause of death decubitus ulcer 1 month duration and pneumonia 4 days duration.

Issue:

Did the nursing home deviate from the standard of care in their treatment of the patient?

If so, is there a causal relationship between their treatment, the development of the ulcer and her ultimate sickness and death?

EXPERT RESPONSES

The differential diagnosis includes: sepsis secondary to infected pressure sore, myocardial infarction and resultant congestive heart failure, pulmonary embolism, ruptured aortic aneurysm and mesenteric infarction
– Dr BT, Nursing Home Medical Director

Based on the info presented, the care was substandard. Pressure ulcers should not be discovered at Stage 3 and should not have progressed given the fact that the nurses had been alerted earlier. If the chart documents the pressure ulcer finding at the time the daughter notified the nurses and if an appropriate care plan was put in place they may not be liable , but without this I think they have a problem.
– Dr KC, Geriatrician

Allowing a patient to remain in a seated without turning and repositioning is a deviation from the standard of care. The death certificate lists decubitus ulcer as an underlying cause of death. The medical records may provide additional information to link the ulcer to the death.
– Dr PS, Nursing Home Medical Director