By Nancy J. Brent, MS, RN, JD

Often nurses get named in a lawsuit when they are involved in clearly negligent conduct that causes an injury to or the death of a patient. Examples include administering the wrong medication to the wrong patient or not positioning a patient correctly in the operative suite prior to surgery. Sometimes, however, the negligent behavior of a nurse is not as clear to the nurse involved in the care of the patient.
That was apparently the circumstance in the reported case, Olsten Health Services, Inc v. Cody.¹ In September 2000, Mr. Cody was the victim of a crime that resulted in paraplegia. He was admitted to a rehabilitation center and discharged on November 15, 2000. His physician ordered daily home health care services in order to monitor his “almost healed” Stage 2 pressure ulcer.² The home health care agency assigned a registered nurse (RN) to Mr. Cody and, after Mr. Cody’s healthcare insurance company would not approve daily visits, a reduced visit plan was approved by Mr. Cody’s physician.

A progressive problem

On November 16, 2000, the nurse visited Mr. Cody for the first time. During that visit, she did an admission assessment and noted that the pressure ulcer, located at the area
of the tailbone, measured 5 cm by 0.4 cm wide and 0.2 cm deep. She believed the pressure ulcer could be completely healed within 3 weeks. The nurse called Mr. Cody’s physician and left him a voice message concerning her visit and her findings.
On November 19, a second visit took place and the nurse observed and documented that Mr. Cody’s pressure ulcer was “100%” pink and no odor was detected.
On November 20, she attempted another visit but did not see Mr. Cody because the front gate surrounding his home was locked. The nurse buzzed the gate doorbell several times to no avail. She left a note on the front gate for the Cody family and left a voice message for Mr. Cody’s physician.

The next visit took place on November 21. The pressure ulcer was now only “90% pink” and had a “fetid” odor; this condition did not improve over the next 24 hours. The nurse documented this fact in her nurses’ notes. Again, she left a voice mail message for the physician concerning these findings.

The nurse could not get into the house on November 23, the next scheduled visit, so she again left a note on the house gate and left a voice mail message for the physician.
On November 24, the home health care nurse saw Mr. Cody and observed the pressure ulcer to be “90% pink” but the “fetid” odor was still present. In addition, Mr. Cody’s right lower extremity was swollen. She was concerned that the wound care that was to be done by the family or the health aide was not being done. Even so, she did not contact Mr. Cody’s physician or the patient again until November 27.

Mr. Cody’s pressure ulcer on November 27 had no odor but the home health aide who was also caring for Mr. Cody told the nurse that he was “very cold and having chills.” The nurse did not document this reported observation in her nurses’ notes.
Attempts to visit Mr. Cody on November 28 and 29 were again unsuccessful because of the locked gate at the front of the house. No one answered the buzzer, either. The nurse left another note on the house gate and left a voice mail message for the physician.

When the nurse saw Mr. Cody on November 30, she observed that the ulcer had “serious changes”: an increase in the serous drainage from the wound; the wound had a “fetid” odor; 80% of the wound was necrotic; the necrotic tissue was “undermined”; and the wound was significantly larger—9 cm by 8 cm wide and 1 cm deep.³ She left a voice mail message for Mr. Cody’s physician, but did not alter her visits to Mr. Cody’s home or attempt to see him over the next 2 days.

Admission to hospital

When the nurse did visit Mr. Cody on December 1, the pressure ulcer consisted of 40% necrotic tissue. She then told the family to take Mr. Cody to the physician’s office. Later that same day he was admitted to the hospital with a Stage 4 pressure ulcer that reached his tailbone. After 3 weeks of treatment, the ulcer measured 20 cm by 30 cm.

Mr. Cody endured many procedures during the following years to treat his
ulcer, but it never really healed. A “flap” enclosure was done to try to cover the wound.

Lawsuit

Mr. Cody sued the home health care company, alleging that the employees breached the standard of care by failing to appropriately diagnose and treat/or to prevent the formation or aggravation of pressure ulcers, resulting in severe and significant injury to him.

Verdict

The Florida Court of Appeals affirmed the trial court’s verdict in favor of Mr. Cody—a $3,050,000 verdict in economic damages⁴—on several legal bases, the most important for the purposes of this article being that the home health care agency and its employees were negligent in the care of Mr. Cody.

Key testimony

Key testimony in reaching this verdict came from the expert testimony of an RN and certified wound care expert. The nurse expert testified unequivocally that the home health care nurse breached the standard of nursing care. She said that not contacting the physician personally about Mr. Cody’s condition and the family being overwhelmed about his condition, but instead leaving voice mail messages on an answering machine, did not meet the standard of nursing care in this situation.
Additionally, the nurse expert testified that the nurse caring for Mr. Cody failed to recognize the symptoms of his deteriorating condition and did not intervene when necessary to avoid the infection he suffered from the deteriorating wound, and that her failure to do so resulted in the development of the Stage 4 ulcer that never healed.

Take-away points

So, what does this case tell you as a wound care professional caring for someone who has a pressure ulcer?

• Meet the standard of care. You must always meet the standard of care when caring for a patient. That means your care must be what other ordinary, reasonable, and prudent nurses caring for a patient with a decubitus ulcer would do in the same or similar circumstances in the same or similar community. Clearly, the nurse did not meet this standard in her care of Mr. Cody.
• Document accurately and completely. Remember that the nurse did not document Mr. Cody’s condition when the home health aide reported it to her. This omission may not only have compromised Mr. Cody’s care. If the communication during the trial became an “I told her”/”I don’t remember being told” debate when each party testified about the communication, it surely caused a rift between the aide and the nurse during the trial proceedings. Such a disagreement between defendant employees always helps a plaintiff’s case.
• Know that photographs can be used in court. This case used a specific form of evidence, demonstrative evidence: photographs taken of the pressure ulcer, which were admitted into evidence during the trial. The photographs were testified to by the wound care expert. In addition to her testimony, this evidence further showed the “natural and continual progression” of the ulcer as it existed on December 1, 2000.
• Understand the importance of expert testimony. In professional negligence cases, expert testimony is essential to establish the standard of care and to provide an opinion as to whether the standard of care was met or breached, the breach of which led to the injury to the patient. Typically, the attorney of a nurse cited in this type of case would want to use a certified wound care expert to support the care given. Apparently, the home care agency’s expert witness was not as convincing as the expert witness’s testimony for Mr. Cody.

Indeed, in this case, the expert witness’s testimony was invaluable and essentially secured a verdict for the plaintiff. Not only was the expert witness board certified but her testimony was credible, based on the evidence presented, and given after a careful review of Mr. Cody’s medical records, admission and discharge summaries from hospitals and health centers that provided care to Mr. Cody, the depositions of several doctors and nurses, and Mr. Cody’s deposition.

• Know your limits. The nurse’s conduct also stresses the importance of another legal principle—knowing the limits of your abilities and capabilities. Nowhere in the reported opinion are the RN’s qualifications listed or a reason given as to why she was selected to care for Mr. Cody. It is assumed she was not certified. Even basic nursing guidelines for wound care and communication to the physician were not followed. Why, then, did she agree to take this assignment? She did so not only at her own folly but to the detriment of Mr. Cody.
• Protect your patient. Last, and by no means least, this case stands for the principle that if you simply document something in the patient’s record that
  is important regarding the patient’s well-being and you just leave voice mail messages for a physician about that “something,” such conduct is not adequate. By simply leaving messages and notes, this RN violated an age-old principle in the law of professional negligence.⁵

Your duty in any situation in which the patient is at risk for a foreseeable and unreasonable risk of harm is to prevent that harm from happening insofar as humanly possible. What those specific steps might be will depend on the circumstances and your patient’s condition. Remember, liability is always fact-specific. Although legal principles exist, how each applies to a particular situation may vary.

Mr. Cody was clearly at risk for a foreseeable and unreasonable risk of harm—the further deterioration of his pressure ulcer. The nurse would only have had to intervene sooner by, for example (and as testified to by the expert witness), personally talking with his physician, visiting the patient more frequently when the deterioration began, contacting social services to help the family with its “overwhelmed” feelings, and following up with the home health aide’s observations of Mr. Cody.

Think about this, too: Nowhere in the court of appeals’ record was it indicated that Mr. Cody’s family or the physician ever received the notes or voice mail messages left by the nurse.⁶ At a minimum, wouldn’t you as the nurse want to follow up and check if those communications had been received?

References
1. Olsten Health Services, Inc. v. Cody, 979 So. 2d 1221 (FL District Ct of Appeals) 2008. (pages 1-8). http://caselaw.findlaw.com/fl-district-court-of-appeal/1160380.html. Accessed June 22, 2012.

2. Id. at 1.

3. Id. at 4.

4. Id. at 2. The doctrine of comparative negligence was used in this case. This doctrine, adopted by most states, reduces a plaintiff’s recovery of money proportionally to the plaintiff’s degree of fault in causing the injury that is the basis of the suit (Blacks Law Dictionary, Second Pocket Edition, Bryan Garner, ed. St. Paul, MN: West; 2001). In this case, the home health care agency’s fault was attributed to be 70%. Mr. Cody’s degree of fault was assessed by the jury at 30%, most probably due to the inability of the home care nurse to be given access into the house on the days she visited and the family not providing the wound care required by Mr. Cody’s decubitus ulcer.

5. This age-old principle was established in a 1965 Illinois case, Darling v. Charleston Community Hospital, 211 N.E. 2d 353 (IL Supreme CT) 1965.

6. Tammelleo D. Treatment of decubitus ulcers botched: verdict for $3,050,000. Nurs Law Regan Rep. 2008;49(1):1.

Nancy J. Brent is an attorney in Wilmette, Illinois. The information in this article is for educational purposes only and does not constitute legal advice.

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Study finds ultrasound therapy improves venous ulcer healing

In a study of 10 venous ulcers not responding to treatment, the use of noncontact ultrasound significantly reduced the wound area over 4 weeks of treatment.

It has been unclear exactly how ultrasound achieves its positive results. The
authors of “A prospective pilot study of ultrasound therapy effectiveness in refractory venous leg ulcers,” an article published online on February 1 by the International Wound Journal, found that patients treated with ultrasound and compression therapy had reduced inflammatory cytokines and bacterial counts, but the reduction wasn’t statistically significant.

The study found another important benefit for patients-reduced pain.

Serum albumin is not a goodindicator of nutritional status

Traditionally the standard of practice for wound care patients has been to review albumin blood levels as a measure of nutritional status and the effect of nutritional interventions. But as noted in The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper, recent studies show that hepatic proteins (albumin, trans­thyretin, and transferrin) correlate with the severity of an underlying disease, not nutritional status. Moreover, many factors can alter albumin levels even when protein intake is adequate, including infection, acute stress, surgery, cortisone excess, and hydration status.

For these reasons, the National Pressure Ulcer Advisory Panel (NPUAP) and the Academy of Nutrition and Dietetics (previously known as The American Dietetic Association) recommend against using serum proteins as a nutritional assessment tool. Evaluation of lab values is just one part of the nutritional assessment process and should be considered along with other factors such as ensuring that the patient receives what is prescribed; daily food/fluid intake; changes in weight status, diagnosis, and medications; and clinical improvement in the wound.

For more information read “Serum proteins as markers of malnutrition: What are we treating?” and “Albumin as an indicator of nutritional status: Professional refresher.”

A profile of outpatients with wounds

“Wound care outcomes and associated cost among patients treated in US outpatient wound centers: Data from the US Wound Registry” a study using data from the US Wound Registry to determine outcomes and costs for outpatient wound care, found the mean patient age was 61.7 years, slightly more than half (52.3%) were male, most (71.3%) were white, and more than half (52.6%) were Medicare beneficiaries.

Other interesting findings:

• The mean number of serious comorbid conditions was 1.8.
• The most common comorbid conditions were obesity/overweight (71.3%), cardiovascular or peripheral vascular disease (51.3%), and diabetes (46.8%).
• Nearly two-thirds (65.8%) of wounds healed, with an average healing time
  of 15 weeks.
• In half of the wounds that healed, patients received only moist wound care and no advanced therapeutics.
• The mean cost for wound healing was $3,927.

The authors of the article, published in March’s Wounds, analyzed 5,240 patients with 7,099 wounds in 59 hospital-based outpatient wound centers in 18 states over 5 years.

LOI index comparable to ABI for assessing PAD in patients with type 2 diabetes

The pilot study “Lanarkshire Oximetry Index as a diagnostic tool for peripheral arterial disease in type 2 diabetes,” published in Angiology, compared the gold standard ankle bra­chial index (ABI) to the Lanarkshire Oximetry Index (LOI) in 161 patients with type 2 diabetes. Researchers assessed the patients for peripheral artery disease (PAD, defined as ABI < 0.9) using both ABI and LOI.

Using a LOI cut-off value of 0.9., the sensitivity and specificity for PAD were 93.3% and 89.1%, respectively. The study concluded that LOI is a “potentially useful alternative diagnostic test for PAD” in patients with type 2 diabetes.

LOI is a noninvasive procedure similar to ABI; both indices indicate whether it’s safe to apply compression to the limb of a patient who has lower leg ulceration or venous hypertension. With LOI, a pulse oximeter is used in place of a hand-held Doppler to determine the index.

Start planning for World Diabetes Day

It’s not too early to begin planning for World Diabetes Day, November 14. Started by the World Health Organization (WHO) and the International Diabetes Federation (IDF), the day is designed to raise global awareness of diabetes.

Access materials, including posters, a campaign book, and the Word Diabetes Day Logo, from IDF’s website, which also has activity ideas.

WHO estimates that more than 346 million people worldwide have diabetes, and the number is expected to double by 2030. World Diabetes Day is celebrated on November 14 to mark the birthday of Frederick Banting who, along with Charles Best, was instrumental in the discovery of insulin in 1922.

Guidelines for PAD in patients with diabetes and foot ulceration published

February’s issue of Diabetes/Metabolism Research and Reviews includes “Specific guidelines for the diagnosis and treatment of peripheral arterial disease in a patient with diabetes and ulceration of the foot 2011,” which is based on two companion International Working Group on the Diabetic foot papers. The guidelines state that if a patient’s PAD is impairing wound healing, revascularization through bypass or endovascular technique must be considered except in a few cases such as severely frail patients. Limb salvage rates after revascularization procedures are about 80-85%, and there is ulcer healing in > 60% at 12 months.

Other points of particular interest to wound care professionals:

• Patients with PAD and a foot infection are at high risk for major limb amputation, so should be treated as a “medical emergency”, preferably within 24 hours.
• Half of patients with diabetes, a foot ulcer, and PAD die within 5 years because of higher cardiovascular morbidity and mortality. Cardiovascular risk management should include “support for cessation of smoking, treatment of hypertension, and prescription of a statin as well as low-dose aspirin or clopidrogel.

AHA statement focuses on PAD in women

“A call to action: Women and peripheral artery disease: A scientific statement from the American Heart Association” summarizes evidence in this area and addresses risk-management issues. The statement notes that women (particularly black females) are more likely than men to experience graft failure of limb loss and calls for more research related to PAD and gender.

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By Nancy Chatham, MSN, RN, ANP-BC, CWOCN, CWS, and Carrie Carls, BSN, RN, CWOCN, CHRN

Moisture-related skin breakdown has been called many things-perineal dermatitis, irritant dermatitis, contact dermatitis, heat rash, and anything else caregivers could think of to describe the damage occurring when moisture from urine or stool is left on the skin. At a 2005 consensus conference, attendees chose the term incontinence-associated dermatitis (IAD).

IAD can be painful, hard to properly identify, complicated to treat, and costly. It’s part of a larger group of moisture-associated skin damage that also includes intertrigo and periwound maceration. IAD prevalence and incidence vary widely with the care setting and study design. Appropriate diagnosis, prompt treatment, and management of the irritant source are crucial to long-term treatment.

Causes

IAD stems from the effects of urine, stool, and containment devices on the skin. The skin’s pH contributes to its barrier functions and defenses against bacteria and fungus; ideal pH is 5.0 to 5.9. Urine pH ranges from 4.5 to 8.0; the higher range is alkaline and contributes to skin damage.

Skin moisture isn’t necessarily damaging. But when moisture that contains irritating substances, such as alkaline urine, contacts the skin for a prolonged period, damage can occur. Urine on the skin alters the normal skin flora and increases permeability of the stratum corneum, weakening the skin and making it more susceptible to friction and erosion. Fecal incontinence leads to active fecal enzymes on the skin, which contribute to skin damage. Fecal bacteria can penetrate the skin, increasing the risk of secondary infection. Wet skin has a lower temperature than dry skin; wet skin under a pressure load has less blood flow than dry skin.

Containment devices, otherwise known as adult diapers or briefs, are multilayer disposable garments containing a superabsorbent polymer. The polymer is designed to wick and trap moisture in the containment device. This ultimately affects the skin by trapping heat and moisture, which may cause redness and inflammation that can progress to skin erosion. This trapping can lead to increased pressure against the skin, especially if the device has absorbed liquid and remains in contact with the skin.

Categorizing IAD

IAD is categorized as mild, moderate, or severe. (See Picturing IAD by clicking the PDF icon above.)

Screening for IAD

Screen the patient’s skin for persistent redness, inflammation, rash, pain, and itching at least daily. To differentiate IAD from pressure ulcers, keep in mind that:

• IAD can occur wherever urine or stool contacts the skin. In contrast, pressure ulcers arise over bony prominences in the absence of moisture.
• With IAD, affected skin is red or bright red. With a pressure ulcer, skin may take on a bluish purple, red, yellow, or black discoloration.
• The skin-damage pattern in IAD usually is diffuse. With a pressure ulcer, edges are well defined.
• The depth of IAD-related skin damage usually is partial-thickness without necrotic tissue. With a pressure ulcer, skin damage depth may vary.

Preventing IAD

The three essentials of IAD prevention are to cleanse, moisturize, and protect.

• Cleanse the skin with a mild soap that’s balanced to skin pH and contains surfactants that lift stool and urine from the skin. Clean the skin routinely and at the time of soiling. Use warm (not hot) water, and avoid excess force and friction to avoid further skin damage.
• Moisturize the skin daily and as needed. Moisturizers may be applied alone or
  incorporated into a cleanser. Typically, they contain an emollient such as lanolin to replace lost lipids in the stratum corneum.
• To protect the skin, apply a moisture-barrier cream or spray if the patent has significant urinary or fecal incontinence (or both). The barrier may be zinc-based, petrolatum-based, dimethicone-based, an acrylic polymer, or another type. Consider using an algorithm developed by wound and skin care specialists that’s customized for skin care products your facility uses. (See Skin care algorithm by clicking the PDF icon above.)

If the treatment protocol fails, the patient should be referred to an appropriate skin care specialist promptly.

To help prevent urine or stool from contacting the patient’s skin, consider using a male external catheter, a female urinary pouch, a fecal pouch, or a bowel management system. Avoid containment devices. If the patient has a containment pad, make sure it’s highly absorbent and not layered, to decrease pressure under the patient.

Managing IAD

A comprehensive multidisciplinary approach to IAD is essential to the success of any skin care protocol. Identify skin care champions within your facility and educate them on IAD. Incorporating administrators, physicians, nursing staff, therapists, and care assistants makes implementation of protocols and algorithms within an institution seamless.

Administrators support the skin care program in the facility, including authorizing a budget so product purchases can be made. The certified wound clinician is the team expert regarding skin care, incontinence, prevention, and product recommendation. The physician oversees protocol development and evaluates and prescribes additional treatment when a patients fails to respond to treatment algorithms. Nursing staff identify patients at risk, incorporate the algorithm into the patient’s plan of care, and direct care
assistants. Therapists address function, strength, and endurance issues to improve the patient’s self-care abilities in activities of daily living to manage or prevent episodes of incontinence.

In severe inflammation, topical dressings, such as alginates and foam dressings, may be used along with topical corticosteroids. In complex IAD, antifungals or antibiotics may be required if a secondary fungal or bacterial infection is suspected.

Additional diagnostic tests may be done to identify and treat secondary infections. These tests may include skin scraping, potassium hydroxide test or Gram’s stain for fungal components, or a swab culture and sensitivity for bacterial infections. If your patient has a suspected secondary fungal or bacterial infection, use appropriate treatments for the full course of recommended therapy. In severe secondary fungal infection, an oral agent may be added to topical therapy. If cost is a concern, consider using a pharmacy knowledgeable about compounding for topical combination therapies.

Referrals and education

For assessment and treatment of under-lying incontinence, refer the patient to a continence specialist if appropriate. Teach the patient strategies for managing incontinence through dietary measures, toileting programs, pelvic-floor muscle training, clothing modification, and mobility aids.

Selected references

Beguin A, Malaquin-Pavan E, Guihaire C, et al., Improving diaper design to address incontinence associated dermatitis. BMC Geriatrics. 2010;10:86. http://www.biomedcentral.com/1471-2318/10/86. Accessed March 15, 2012.

Black JM, Gray M, Bliss DZ, et al. MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis. J Wound Ostomy Continence Nurs. 2011; 38(4):359-370.

Bliss DZ, Zehrer C, Savik K, et al. An economic evaluation of four skin damage prevention regimens in nursing home residents with incontinence: economics of skin damage prevention. J Wound Ostomy Continence Nurs. 2007;34(2):143-152.

Denat Y, Khorshid L. The effect of 2 different care products on incontinence-associated dermatitis in patients with fecal incontinence. J Wound Ostomy Continence Nurs. 2011;38(2):171-176.

Doughty DB. Urinary and Fecal Incontinence: Current Management Concepts. 3rd ed. St. Louis, MO: Mosby Elsevier; 2006.

Gray, M. Optimal management of incontinence-associated dermatitis in the elderly. Am J Clin Dermatol. 2010;11(3):201-210.

Gray M, Beeckman D, Bliss DZ, et al. Incontinence-associated dermatitis: a comprehensive review and update. J Wound Ostomy Continence Nurs. 2012;39(1):61-74

Gray M, Bliss DZ, Doughty DB, et al. Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2007;34(1):45-54.

Gray M, Bohacek L, Weir D, et al. Moisture vs pressure: making sense out of perineal wounds. J Wound Ostomy Continence Nurs. 2007;34(2):134-42.

Institute for Clinical Systems Improvement. Health care protocol: Pressure ulcer prevention and treatment. Bloomington, MN: Institute for Clinical Systems Improvement. January 2012. http://www.icsi.org/pressure_ulcer_treatment_protocol__review_and_comment_/pressure_ulcer_treatment__protocol__.html. Accessed March 15, 2012.

Junkin J, Lerner-Selekof JL. Prevalence of incontinence and associated skin injury in the acute care inpatient. J Wound Ostomy Continence Nurs. 2007;34(3):260-269.

Landefeld CS, Bowers BJ, Feld AD, et al. National Institutes of Health state-of-the-science conference statement: prevention of fecal and urinary incontinence in adults. Ann Intern Med. 2008;148(6):449-458.

Langemo D, Hanson D, Hunter S, et al. Incontinence and incontinence-associated dermatitis. Adv Skin Wound Care. 2011;24(3):126-142.

Scheinfeld NS. Cutaneous candidiasis workup. 2011 update. http://emedicine.medscape.com/article/1090632-workup. Accessed March 15, 2012.

U.S. Census Bureau. The older population 2010. November 2011. www.census.gov/prod/cen2010/briefs/c2010br-09.pdf. Accessed March 15, 2012.

Nancy Chatham is an advanced practice nurse at Passavant Physician Associates in Jacksonville, Illinois. Carrie Carls is the nursing director of advanced wound healing and hyperbaric medicine at Passavant Area Hospital in Jacksonville, Illinois.

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