Managing pressure ulcer risk in long-term care: claiming to provide good care is not enough--facilities need appropriate products and documentation. (Feature Article).

While the average number of residents with pressure ulcers in any given facility is typically less than 10% of all residents, plaintiff attorneys have realized that juries are sympathetic and, typically, render enormous verdicts against providers where bedsores are prevalent. Just one resident with a pressure ulcer could potentially bring an enormous settlement or verdict, and disaster for the facility.

Statistically, only 9% of all residents in nursing homes nationwide have pressure ulcers, with approximately half of those being acquired while residents are under the facility's care. These are referred to as nosocomial wounds, and they pose the largest threat for litigation. Providers are often vulnerable, though, to pressure sores that actually started while the resident was either in the hospital or in the care of a family member. Even in attempting to manage the pressure ulcer, providers are hindered by the inadequacy of state and federal reimbursement to fund prevention and early intervention.

Thus, while state surveyors will cite facilities for deficient practice if a resident develops a nosocomial wound, neither Medicaid nor Medicare will specifically reimburse the facility for pressure-reducing surfaces used for prevention. The only means remaining for reducing pressure for residents at risk is for the direct-care staff to reposition the resident every two hours. In the real world of nursing home care and staffing, we know this does not occur with absolute consistency.

The facility has no choice: For any resident assessed to be at risk, or who already has a wound, timely assessments and the use of appropriate pressure-reducing surfaces are critical to primary prevention. This wound-prevention protocol should be coupled with good documentation of all treatment measures, dietary adjustments and overall communication with the resident's physician. For those residents confined to a wheelchair, a wheelchair cushion must be used.

Why should all these steps be taken? Because providers can no longer afford to defend themselves by claiming they "turn and reposition the resident every two hours" unless they can prove it, as this will be exploited in the discovery phase of the litigation. Medical record reviews typically show a lack of documentation for this repositioning, thus allowing the plaintiffs bar to contend, "If it's not documented, it didn't happen."

If a resident has a wound that is "clinically unavoidable"--and this does occur--the facility needs to make sure that the resident's physician has documented this fact in the resident's care plan. This in itself can defuse potential litigation early on.

In short, careful--and documented--attention to every resident's skin health is not only a "best practice," it could be the key to the facility's survival in today's litigious world.

Allan Thomas is president of TAGWEB, a healthcare consulting firm specializing in risk-mitigation services for nursing homes and assisted living facilities nationwide. For further information, phone [phone] or visit www.tagweb.com. To comment on this article, please send e-mail to [e-mail].