What Information Should a Facility Document in Individuals with Bed Sores?

By Nursing Home Law Center

Facility Information DocumentationBed sores afflict many nursing home and assisted living facility patients every year in the United States. Various studies have reported incidence rates of 11% to as much as 28% when it comes to individual bed sore risk in nursing homes.

One of the most vital aspects of bed sore prevention and treatment is individual health monitoring. Older individuals are less resistant to injury and illness than younger people and therefore require more extensive and comprehensive care.

When nursing home staff treat patients and document bed sore incidents, there are various data points they should collect to develop appropriate individualized treatment plans and prevent the occurrence of bed sores among patients in the future.

Proper Documentation for Bed Sores

Most nursing homes, assisted living facilities, and acute medical treatment facilities adhere to a weekly monitoring schedule for patients with bed sores. Each week, attending caregivers should measure a patient's bed sores, check for signs of growth or decline, and note various other aspects of the patient's health.

Assessment findings for a bed sore case should include the size, color, position, and stage of a patient's bed sore. This report should also indicate whether the pressure ulcer shows any signs of tunneling or undermining, the amount of drainage coming from the wound, and descriptions of the wound edges and wound base tissues.

During weekly bed sore assessments, caregivers must also take note of the patient's overall wellness and clarify any symptoms of infection, such as fever, malaise, increased white blood cell count, swelling, and the temperature of the surrounding tissue. Attending caregivers should encourage patients to provide honest and thorough descriptions of their pain symptoms, including location, intensity, and changes in severity with movement or throughout the average day.

Ultimately, there are many risk factors that can increase the chance of a nursing home patient developing a pressure ulcer, and there are many issues that can arise during the recovery phase that may impact the patient's ability to heal.

A nursing home patient's medical chart should contain weekly assessment reports that thoroughly address all aspects of the patient's individual medical concerns and specific factors concerning the patient's pressure ulcers. If loved ones notice this information missing from a patient's chart, this could be an indication he or she has not received the treatment required to heal.

Individual Health Factors That Increase Risk of Pressure Ulcers

Generally, nursing home staff should reposition a patient every two hours to prevent bed sores. However, some patients are at increased risk of developing bed sores and may require more frequent turning. Others may have medical complications that make repositioning more difficult, such as hip fractures and other injuries from falling. Nursing homes have a responsibility to develop individualized treatment plans that address each patient's unique health concerns.

Patients who qualify as malnourished according to the Body-Mass Index (BMI) scale, diabetic patients, and those suffering from blood pressure-related conditions also face an increased risk of developing pressure ulcers. If a patient requires any type of surgical treatment for an ailment or injury, he or she faces an increased risk of bed sores during recovery, when he or she will likely remain in bed for most of any given day.

Nursing Home Liability

If a nursing home fails to uphold proper procedures for tracking and treating patients' bed sores, it is likely the nursing home will absorb liability should the patient develop bed sores and any secondary conditions such as infection. A bed sore is a preventable injury with careful, individualized treatment for nursing home patients. When nursing home staff allow bed sores to harm patients due to poor tracking and documentation practices, injured patients and their loved ones may have grounds for legal action against the responsible party.

An investigation into a bed sore claim will likely involve the nursing home's care records and medical chart for the patient in question. Any lack of documentation or failure to account for known risk factors will almost undoubtedly shift liability for the bed sores to the nursing home and/or staff members.


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