This senior care case involves an 84-year-old male with a medical history significant for CVA, cachexia, hypertension, type II diabetes, and mild anemia. The patient recently suffered a CVA with left hemiparesis and was discharged to a nursing home for further care. The patient’s condition deteriorated immensely upon his transfer to this facility and it was at this point he was made DNR/DNI. Over the course of his stay, the patient developed several pressure ulcers, several leg contractures, and required a peg tube as he became more malnourished. Complications over the course of one year included urinary tract infections, pneumonia, kidney failure, chronic pain syndrome, and arterial and small vessel disease. Additionally, the patient was severely dehydrated and malnourished over the last several weeks of his life, and his health began to decline so much that he was no longer able to use his dentures, even when fitted with special adhesives. He developed gangrene of his right heel and had to undergo several rounds of surgical debridement that ultimately required several amputations, including his right hand. After an unsuccessful hand transplant in the aftermath of his amputations, the patient’s health fatally declined. The cause of death was listed as Legionella pneumonia, hypertension, hyperlipidemia, and atrial fibrillation. No autopsy was performed. An expert with a specialty in decubitus ulcer care was retained for this case.

This is an elderly male with multiple comorbidities contributing to his functional and clinical deterioration and if anything could have been managed better it seems as though the pressure ulcer monitoring was substandard. The most important care for a patient at risk for pressure ulcers and those with bedsores is the redistribution of pressure so that limited pressure is applied to the spot of the ulcer. The frequency of turning and re-positioning depends on the level of risk in the patient. Turning patients every 2 hours has been a long-standing tradition, with some evidence to support its practice. Pressure-redistribution mattresses are used to reduce high values of pressure on prominent or bony areas of the body. This patient seems as though he was at the end of his life but that does not mean that he doesn't deserve the same preventative care as the next patient.

1. Should this patient have been monitored more closely and what could have been done to prevent such outcomes?

Location: Maryland B.S., Cal State University M.A., Health Administration, Clark University M.D. University of California at Los Angeles School of Medicine Residency, Internal Medicine, University of California at Los Angeles Fellowship, Hospital Medicine Board Certification: Internal Medicine Member, American College of Physicians Member, Society of Hospital Medicine Former A******** C******* P******** Former M****** D******* E************** H******* Former M****** D******* P****** C*** I********* Former F****** I******* M******* P****** P******* Current M****** D******* H********** P****** a* m**** h********* n******

This board certified internal medicine specialist has acquired multiple high ranking clinical and administrative leadership positions in healthcare management throughout his 20+ year medical career. These include medical directorships at major healthcare networks, where he has been responsible for the health and safety precautions as well as clinical protocol management.

Elderly Man Not Properly Cared for in Nursing Home

This case involves an elderly patient, undergoing treatment for many conditions, who developed a distal right common iliac thrombus occlusion. During the hospital stay, the patient underwent an embolectomy and femoral-popliteal bypass. The patient also developed cellulitis of the right lower leg, ecchymosis, and a grade 1 ulcer on the right heel. While under the care of this hospital, the patient developed several decubitus ulcers that went unchecked for a significant amount of time. The hospital failed to make a proper, adequate, and timely diagnosis, which led to a delay in treatment of the bedsores. The patient died and the cause of death was a severe staph infection linked to the ulcers. An expert with a specialty in decubitus ulcer care was retained for this case.

The first step in resolution is to reduce or eliminate the cause, that is, pressure. A multidisciplinary approach can lead to maximum benefit for the patient. Consultations with a neurosurgeon, urologist, plastic surgeon, orthopedic surgeon, and general surgeon all may be indicated in a particular patient. A rehabilitation medicine specialist, social worker, and psychologist or psychiatrist may work together with geriatricians or internists to improve the patient's health, attitude, support structure, and living environment. When medical management has been optimized, many stage I and stage II pressure sores heal spontaneously. Stage III and stage IV ulcers, however, almost always require a surgical approach. Plastic surgeons perform most pressure sore reconstructions, and consulting a plastic surgeon with any complex or chronic wound is appropriate.

1. How much medical attention should be given to pressure ulcers in a patient who has several comorbid conditions?

Location: New York B.S., Biochemistry, Stony Brook University M.D., University of Cincinnati College of Medicine Residency, General Surgery, Stony Brook University Hospital Board Certification: Surgery, Preventative Medicine Pending Member, Undersea & Hyperbaric Medical Society Pending Member, New York County Medical Society Member, Association for Academic Surgery Published, 3 major medical publications Former A******** S****** B******** M****** C***** Former A******** S****** N**** S**** S****** H******* Former A******** S****** L*** I***** H********* & W**** C*** A********* N* Former M****** D******* D********* o* A******* W**** C*** & H********* M******* Current A******** P******** o* S****** a* m**** N* m****** s***** Current D******* D********* o* W**** C*** a* a N* h******** Current G**** S****** o* D** R**** o* t***** i* W**** H******

This qualified expert is an actively practicing, board-certified general surgeon. He has performed laparoscopic cholecystectomies since 1990, in addition to his primary fields of general surgery and wound care.

Elderly Patient Dies From Untreated Bedsores

A nursing home administration expert witness advises on a case involving an elderly female patient who on August 14, 2014, fractured her pelvis. A pelvic x-ray revealed a left parasymphysis pubis fracture not involving the acetabulum. She was hospitalized as an inpatient on August 18, 2014. On August 22nd, she had her first physical therapy session in the Delaware hospital. During therapy she put little weight on her left lower extremity due to pain, yet she performed ankle pumps, hip abduction and adduction, long arc quads and marching for 5-10 repetitions. Physical therapy would consist of gait training, bed mobility, transfer training, balance training and therapeutic exercise. The patient was significantly limited due to pain in her left groin and required minimum to moderate assistance for transfers with little ambulation due to painful weight bearing. The therapist felt the patient would benefit from continued physical therapy services and recommended rehabilitation at a skilled nursing facility prior to discharge home. On August 31st, the patient was transferred to a nursing home where she relied on staff for assistance with bed mobility, transfers, toilet use and personal hygiene. Shortly after admission, she described pain in her hips at 10/10 on the pain scale and was given Morphine Sulfate. While a resident at the nursing facility, she was often left in her bed for hours at a time in excruciating pain. At times, the sheets on her bed were tucked in at the edge of her bed so that her ankles and feet were pressed downward and inward for extended periods of time. The patient developed a sacral coccygeal decubitus ulcer and severe bilateral plantar flexion contractures.

I have an active academic geriatric medicine and palliative medicine practice, and I see patients in inpatient, nursing home, and outpatient clinic settings. Patients with problems similar to the patient described in this case are not uncommon in my practice. In general, frail older patients with pelvic fractures who are appropriate for rehabilitation based on their care goals (which appears to have been the situation in this case) would typically undergo post-acute rehabilitation in a skilled nursing facility including physical and occupational therapy, along with re-positioning by facility staff as needed either for comfort or for impaired bed mobility. Patients who exhibit marked impairment of bed mobility and limited mobility due to pain would be at increased risk for complications of immobility and a failed course of rehabilitation and should be identified and case-managed accordingly. I have cared for patients who don't do well after a serious injury and who eventually develop complications of immobility such as pressure sores. The bad outcome of pressure sores doesn't necessarily indicate poor care (although it certainly could result from poor care), but the development of pressure sores in a low risk nursing home patient (e.g., one who is initially mobile, cognitively intact, and well nourished) is considered a marker of poor care. What is important is to identify potential risk factors for pressure sores as early as possible, to develop a comprehensive, interdisciplinary care plan to mitigate these risks as much as possible, and to modify the plan as needed for changing circumstances. A careful chart review can often identify whether an appropriate care planning process was in place.

1. Do you routinely treat patients similar to the one described in the case? 2. How/when do you determine if the necessary care and services include physical therapy and re-positioning? 3. Have you ever had a patient develop the outcome described in the case? 4. Do you believe this patient may have had a better outcome if the care rendered had been different? 5. Have you ever served as an expert witness on a case similar to the one described above?

Location: Washington B.A., Biology, Reed College M.D., University of Chicago/Pritzker School of Medicine Internship, Internal Medicine, University of Washington Residency, Internal Medicine, University of Washington Fellowship, Gerontology & Geriatric Medicine, University of Washington Fellowship, Palliative Care, King's College London Board Certification, Internal Medicine Board Certification, Geriatric Medicine Board Certification, Hospice and Palliative Medicine Fellow, American College of Physicians Member, American Geriatrics Society Member, American Academy of Hospice and Palliative Medicine Member, Multiple Sclerosis Center of Excellence West Honor, Pfizer/American Geriatrics Society Postdoctoral Fellowship Award Published, 17 peer-reviewed journal articles Authored, 26 books and 17 book chapters Former A***** A******** P******** o* M******* U********* o* W********* Former S**** P******** G****************** C*** V* P**** S**** H***** C*** S***** Current M****** D******* P********* C*** a** H****** S****** m**** h***** c*** s***** Current A******** P******** o* M******* m**** u*********

Northeast

Delaware

This highly qualified Gerontology and Geriatric Medicine expert is triple board certified and a Fellow of the American College of Physicians. He is Fellowship trained in Gerontology & Geriatric Medicine as well as Palliative Care. This expert is a Fellow if the American Geriatrics Society and a member of several professional organizations including the American Geriatrics Society. he has won countless awards throughout his career including the Pfizer/American Geriatrics Society Postdoctoral Fellowship Award. He is active in the research community with his projects attracting millions of dollars in funding. He has published 17 peer-reviewed journal articles and has authored 26 text books. He currently serves as Medical Director of the Palliative Care and Hospice Service at a major health care system in addition to his Professorship at a major university.

Nursing Home Administration Expert Witness Advises on Neglected Patient’s Bedsores

This case involves an elderly woman who was admitted to the hospital in order to undergo a procedure to remove her kidney following a cancer diagnosis and attempted tumor cryoablation. The surgery went well, and there were no complications noted, however due to the patient’s advanced age and poor health her recovery time was extensive. Following her surgery, she remained in the same hospital in which she underwent surgery for a period of several weeks. During that time, the patient developed stage IV bedsores, which caused a life-threatening systemic infection. The patient recovered, however she required an extended hospital stay and suffered permanent injuries as a result of the sores and subsequent infection.

I regularly treat and monitor surgical patients in a post-operative setting. I am the clinical nurse manager of a large orthopedic, urology, and cardiac step down unit at our facility. We see quite a few bedsores and follow a protocol for prevention, staging of current pressure ulcers, and treating the wounds. In addition, I have had numerous patients who have had Nephrectomies. I am the President of my State Board of Nursing and have been since 2012. I would need to know the exact length of stay, whether the patient was turned, if the could patient turn herself, if the patient or family refuse turning, what her nutritional status was, her weight, as well as any co-morbidities. Length of stay for my patients who have had a nephrectomy is generally 4-5 days without complications. A stage 4 pressure ulcer is full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. This type of ulcer can include undermining and tunneling. The depth of a stage IV pressure ulcer varies by anatomical location. Stage IV ulcers can extend into muscle and supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis possible. Exposed bone and tendon is visible or directly palpable in Stage IV ulcers.

1. Do you treat and monitor surgical post-operative patients? 2. How often do you see patients with bedsores? 3. What measures should be taken to prevent patients from developing bed sores?

Location: Arkansas Nursing Diploma, Jefferson School of Nursing B.S., Gerontology, University of Arkansas-Pine Bluff Certified: Registered Nurse, BLS Instructor, AHA Mid-Management, ACLS Former P******** A******* S**** B**** o* N****** Former N**** J******** R******* M****** C***** Former O********* N**** S**** A******* O********* C***** Former R********* H*** H***** N**** J******** H*** C*** Present, Clinical Nurse Manager in Orthopedics and Urology Unit, Arkansas-based medical center

This expert currently serves as a clinical nurse manager in the orthopedics and urology unit at a medical center in Arkansas. She earned her nursing diploma from Jefferson School of Nursing and a BS in Gerontology from the University of Arkansas - Pine Bluff. This expert is a registered nurse and is the former president of the Arkansas State Board of Nursing.

Nursing Expert Discusses Post Surgical Bedsore Development

This case involves a woman who developed pressure sores following a surgical procedure. The patient was admitted to an inpatient rehabilitation facility and was not found to have any pressure wounds at the time of admission. The patient was primarily sedentary during her time in the facility, however, the records indicate that the patient was not routinely assessed for pressure wounds. After 3 weeks, the patient was discovered to have an advanced stage pressure sore on her tailbone. The patient was transported back to the hospital and was diagnosed with sepsis and an infected pressure sore with foul-smelling drainage. The patient developed an infection in her bone secondary to the pressure sore. She required surgical intervention and debridement to treat the wound. An expert in wound care was sought to review the records and opine on the standard of care for prevention of pressure sores.

I am a certified registered nurse and a nurse practitioner specializing in wound, ostomy, and continence care. I am also the director of clinical operations at a large university medical center in the mid-Atlantic. I have worked with wounds and skin issues since 1993, both lecturing and publishing on the topic at the local, regional and national level. Getting people moving is essential to prevent pressure injuries. Assisting in position changes, encouraging position changes, and educating individuals on the importance of position change are all part of the standard of care. We are finding out that pressor use in the ICU setting is having an impact on the formation of pressure injury following cardiac surgery and other serious illnesses. Many pressure injuries initiate before they occur. In addition to prevention strategies, identifying initial issues and prompt intervention can prevent worsening.

1. Please describe your background in wound care. 2. What measures can be taken to prevent decubitus ulcers in rehabilitation patients?

Sedentary Patient Develops Pressure Sores During Rehabilitation

This case involves a civil rights action against the police department of a major west coast city. A 32-year-old wheelchair bound plaintiff was arrested for drug-related charges in a local bar. The plaintiff had several pressure ulcers as a result of time spent in his wheelchair. Upon his arrest, the plaintiff was taken to the precinct, removed from his chair and placed on a wooden bench in a holding cell. The cell was not handicap accessible, and lacked cushions or grab bars. The plaintiff was not moved from the wooden bench for over 12 hours causing a shearing effect on his ulcers and the development of new ulcers. The plaintiff required several corrective surgeries.

I am a critical care surgeon with an interest in wound healing. I have extensive experience with wound care as well as the management of decubitus ulcers. I care for many patients with complex wounds all over their bodies both traumatic and non-traumatic in nature. I have published numerous articles and research on wound healing. I am also the associate medical director of the injury and violence prevention program at a major university program. Unfortunately, patients with mobility issues are prone to the development of pressure ulcers so to speak. These can be very challenging to manage and at times become chronic in nature and in bad situations can even cause fulminant sepsis. Many of the reconstruction options available to these patients do not work because of continued pressure on the area or chronic infections which often are unable to be cleared. I am able to review this case and determine whether the care of this patient resulted in the development of the pressure on itself or worsening of his current ulcer.

1. What is your experience in wound care, specifically treating patients with ulcers? 2. How would you determine whether the treatment by the defendants resulted in the deterioration of the patient's ulcers?

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Bedsore Expert Witness Case Studies

Elderly Man Not Properly Cared for in Nursing Home

Elderly Patient Dies From Untreated Bedsores

Nursing Home Administration Expert Witness Advises on Neglected Patient’s Bedsores

Nursing Expert Discusses Post Surgical Bedsore Development

Sedentary Patient Develops Pressure Sores During Rehabilitation

Police Department Infringes On Civil Rights Of Handicap Arrestee

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