Department of Health in Virginia Put Out an Important Safety Alert for Pressure Injuries

By Jeffrey J. Downey, Esq

Virginia’s Department of Behavioral Health and Developmental Services, Office of Integrated Health, released a Pressure Injury Health & Safety Alert. Although pressure injuries/ bedsores are preventable, nursing home patients commonly develop these injuries, which can lead to morbidity and mortality. A pressure injury (PI), also known as a decubitus ulcer, a bedsore, or a pressure ulcer, is an injury to the skin and the underlying tissue resulting from prolonged pressure.

Risk Factors

Friction, moisture, and shearing are common factors that increase a person’s chance of getting a pressure injury.  Friction injuries occur when the skin is dragged or pulled across a surface, like when an individual is moved across bed sheets. Friction, and risk of a friction injury, is increased if the skin is moist, resulting in more extensive skin and tissue damage.

Skin can become moist for a variety of reasons. Incontinence and sweat can be major contributors to moisture. Moisture can become trapped between skin and fabrics which can increase the risk of developing a PI. This is a common occurrence for individuals who repeatedly sit in soiled bedding, clothing, or diapers for prolonged periods of time.

Shearing injuries occur during repositioning when the body is not lifted off the surface completely— this movement pulls the bones in one direction and the skin in the other. A shear injury is not seen on the outside of the body—they occur beneath the skin when the blood supply is cut off to the tissue under the skin surface, which results in cell death (necrosis).

Individuals at Increased Risk

Individuals at increased risk for pressure injuries should have an ongoing risk-prevention protocol in place to routinely monitor their skin. This protocol should include documenting and reporting any early signs of prolonged pressure to a healthcare professional.

Some groups of individuals with an increased risk of developing a PI include, non-ambulatory individuals, older individuals, individuals diagnosed with diabetic neuropathy, individuals diagnosed with PAD, individuals with spinal cord injuries or paralysis, individuals with severe cognitive impairment or brain injury, individuals with incontinence, individuals with communication difficulties.

Diagnosis & Treatment

Some of the earliest and most common signs of prolonged pressure on the skin are changes in color or appearance, swelling and/or prolonged redness, and warmth to the touch. It is important to recognize these signs early and bring them to the attention of the individual’s primary care provider, nurse, or wound care specialist immediately to stop them from progressing further.

Not all medical professionals are qualified to take care of a loved ones’ pressure injury. Healthcare professionals who are qualified to stage a pressure injury include physicians, nurses, and board-certified wound specialists.   In most states assisted living facilities are not allowed to accept or keep patients who have pressure wounds beyond stage II.

Once a bed sore has been identified, the healthcare professional should examine the injury, determine the severity (also known as staging), and begin the treatment protocol. There are 5 stages of pressure injuries, ranging in severity from (1) discolored, intact skin to . . .  (5) severe tissue loss appearing as empty hole.

An individual’s Pressure Injury Treatment Plan should be tailored to the individual’s specific needs and should include a thorough assessment to determine the cause and diagnosis. Generally, PI Treatment Plans might also include information on wound care, pain management, repositioning protocol, transferring protocol, nutrition, and physical and/ or occupational therapy.

Caregiver Prevention

Educating caregivers and direct support professionals about how pressure injuries occur is the first step in lowering the risk of these injuries. Individuals should have a person-centered plan in place to monitor and address areas of risk, and all staff and caregivers should be fully trained on protocols to ensure proper care is being administered.

A quality PI prevention program includes individualized protocols, as well as standard policies and procedures aimed at addressing routine skin assessments and skin care. Skin assessments need to be performed regularly by all caregivers who can recognize that signs of redness, edema, localized heat, or induration (hardness) are warning signs of PI development. Caregivers need to be trained to provide routine skin care and should be taught the steps and methods to keep the skin clean, dry, and free of urine, stool, or sweat. A routine, scheduled protocol for checking and documenting individuals for soiling should be implemented to ensure individuals are kept clean and dry.

Incontinent individuals should be monitored at more regular intervals during the day and night. Individuals who are incontinent and wear diapers could suffer skin breakdown and infection if they are not routinely changed and repositioned.

Inspecting the skin and seeking treatment from a medical professional can reduce long term complications during a PI. Applying a lubricant cream or lotion per a health care provider’s prescription is a valuable part of skin care because well lubricated skin prevents breakdown and reduces chances of skin becoming torn and/or infected.

Positioning & Devices Prevention

Individuals should be repositioned frequently to alleviate pressure to the skin’s surface. Standard Repositioning protocols call for repositioning every two hours, however, schedules or protocols need to be individualized based on tissue tolerance, patient rights, and the specific support surface being used.

Properly changing an individual’s position means that the individual will be in a completely different position than they were previously. All individuals should be supported or positioned using a “support surface,” which is a generic term that encompasses all surfaces and specialized devices which are used for positioning and pressure redistribution. Shearing, PI and other injuries are more likely to occur when individuals are moved without a support surface.

Routine seating assessments, performed by a healthcare professional, are recommended for any individual who spends a significant amount of time in a wheelchair. The most common sites for pressure injuries in wheelchair users are the: Scapula, Sacrum/Coccygeal area, Ischial tuberosity, Heel, Ball of the foot, Back of the knee, and Elbow.  If the individual has a history of any PI, pressure mapping should be included in the individual’s seating assessment to help select the proper seat cushion. In addition, lateral supports, padded arm rests, customized/ specialty cushions, and specialty beds/ mattresses are all options to those who are high risk or have had pressure injuries.

A Call to Action – Protect your rights now by calling an experienced malpractice attorney

If you have questions about pressure injuries or want to have a case reviewed to determine if a facility or healthcare provider negligently caused a pressure injury, call the Law Office of Jeffrey J. Downey for a free consultation.   You pay no attorney’s fees unless there is a recovery.  Mr. Downey has over 30 years of experience handling malpractice and elder neglect cases, including pressure wound cases. He practices in Virginia, Maryland, Washington DC and New York.

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