Signs or Symptoms of Abuse or Neglect
Pressure Sores, Decubitus Ulcers or Skin Breakdown
Pressure wounds can be a sign of neglect in long term care facilities. As patients age, they become at increased risk for skin breakdown. It is estimated that some 2.5 million patients develop pressure wounds (a/k/a bed sores) every year, in both hospitals and rehab facilities, costing the US taxpayers an estimated 9 to 11 billion dollars a year.
More than 60,000 patients die annually from pressure wounds. Medicaid has estimated that each pressure wound adds $43,180 in costs to a patient’s hospital stay. (Adverse Events in Long term care residents transitioning from Hospital back to Nursing Home, Alok Kapoor, MD, JAMA Intern Med 2019:179(9); 1254-1261).
A prospective study of 555 long term care residents found that adverse events developed 37.3% of the time when patients are being discharged from hospitals to nursing facilities. Of these events, 70.4% were preventable, with skin tears, pressure ulcers and falls being the most common adverse events. Under changes to Medicare regulations, hospitals can lose reimbursement where they allow patients to develop preventable bed sores or pressure ulcers.
Pressure wounds are staged from one to four, with stage four (IV) being the deepest and most potentially lethal wound. Stage 4 pressure wounds can be down to the bone. Sometimes wounds are described as unstageable because it is impossible to determine their depth due to overlying dead tissue.
Common locations for pressure wounds include the following:
- Sacrum (the large bone at the base of the spine just above the tailbone)
- Coccyx (tailbone)
- Heels of the feet
- Sides of the hips (more specifically, parts of the femur called trochanters and the iliac crests of the pelvis)
- Pelvic “sit bones” where weight is placed when sitting (called the ischial tuberosity)
- The back along places where the vertebrae protrude
- Any areas of the head that are in contact with the bed surface, a pillow, etc.
While the monetary losses associated with the development of such wounds are significant, even more important is the reality that pressure wounds adversely impact a patient’s quality of life and mortality. Elders who develop open wounds often develop infections and other complications that can severely limit or end their quality of life.
Unlike some mysterious illness or incurable disease, the causes of bed sores and methods of prevention are well known to the industry. However, since their prevention in high risk patients is complex and labor intensive, a systematic approach is required to consistently offload (reduce) pressure and coordinate other disciplines, like dietary and rehab departments.
Hospitals and rehab facilities need to place a strong emphasis on quality improvement. There are great resources providing tools and recommendations for reducing the incidence of pressure wounds. Recommendations include, inter alia, complete body checks every shift, use of a turning and repositioning schedule and repositioning as often as every hour for patients who are completely immobile. Frequent reassessment is required to change any care plan that is not working to increase offloading frequency and evaluate other modalities, like an air fluidized bed.
Independently evaluating and treating any nutritional deficiencies is a critical part of any prevention or treatment regimen. Pressure Ulcer and Nutrition, S. Saghalieine, Kasra Dehgman. This author explains that increased needs for energy, protein, zinc, and Vitamins A, C, and E and also amino acids such as arginine and glutamine have been well documented in the literature. Hydration plays a vital role in the preservation and repair of skin integrity. Dehydration, a common problem in the elderly population, disturbs cell metabolism and wound healing.
If your loved one develops a pressure wound at a facility, insist on being updated daily on the wound’s progress and make sure the patient is kept clean and is being turned frequently. You should take pictures of the wound to track its progress and if the facility is not responsive to this problem or it gets worse, you should consider discharge to another facility.
For additional information on pressure wounds review the following link: Pressure Wound/ Decubitus Ulcer.