Malpractice Case Study: Inadequate Pressure Ulcer Prevention in Inpatient Rehabilitation Facility

Failure to follow regulations and institutional policy can lead to regulatory intervention, which then hampers the defense of any subsequent litigation. This case demonstrates the importance of leadership oversight and the application of evidence-based pressure ulcer prevention protocols in inpatient rehabilitation facilities to improve resident outcomes and enhance regulatory compliance.

Allegation

The estate of an elderly resident alleged that the rehabilitation facility failed to assess, monitor, and document skin integrity, nutritional intake, and repositioning practices, resulting in the development and progression of pressure ulcers, infection, and subsequent death.

Background

An elderly patient was admitted to a rehabilitation facility following hospitalization for weakness and deconditioning. The plan of care included physical therapy, nutritional monitoring, and nursing support for mobility and safety. The resident had comorbid conditions including diabetes and mild cognitive decline and required significant assistance with activities of daily living.

During the stay, nursing documentation showed inconsistent entries related to repositioning, skin assessment, and nutritional intake. The electronic record contained generic care plan statements but lacked individualized interventions for skin integrity or evidence of resident and staff education on turning schedules. Progress notes reflected minimal risk factor reassessment, and interdisciplinary communication about the resident’s declining condition was limited.

By the second week, the resident developed pressure ulcers on the left heel and posterior leg, which worsened despite wound care. The resident was transferred to an acute care hospital for surgical debridement. During that hospitalization, the patient was also diagnosed with a urinary tract infection. Upon return to the rehabilitation facility, the resident’s condition deteriorated, resulting in death two months later from complications of sepsis.

Around the same time, the facility underwent three state surveys, all citing deficiencies in skin integrity management and documentation. The case was settled pre-trial following significant regulatory findings supporting the allegations.

Key Contributing Factors in the Claim

Patient Care Deficiencies

• The plaintiff’s nursing expert testified that the standard of care of consistent assessment and documentation of skin condition, turning and repositioning every two hours, and nutritional intake monitoring was not met.
• The expert noted that the facility’s pressure ulcer protocol was outdated and lacked reference to current standards of care.

Documentation Deficiencies

• The care plan failed to reflect individualized risk-based interventions.
• Nursing staff failed to document preventive measures and physician notification of changes in status.

Patient Safety Considerations

Strengthen Documentation and Care Planning

• Implement electronic documentation prompts or checklists for repositioning, nutrition, and pain management entries for each shift.
• Require interdisciplinary review and updating of care plans when risk scores change or skin condition worsens.
• Conduct monthly documentation audits with performance feedback to staff.

Standardize Pressure Ulcer Prevention Protocols

• Adopt an updated skin integrity protocol based on current guidelines.

Educate Staff and Validate Competency

• Provide annual competency-based education on skin assessment, repositioning techniques, and documentation standards.
• Include case-based simulations illustrating the consequences of poor documentation.

Ensure Leadership Oversight and Quality Monitoring

• Establish a Skin Integrity Committee to review wound trends and documentation compliance.
• Track pressure injury rates, care plan compliance, and audit results in quality dashboards.
• Conduct root cause analyses on any facility-acquired pressure injuries and communicate lessons learned facility-wide.

This case highlights how documentation, individualized care planning, and ongoing staff training remain critical to both resident safety and legal defensibility.

For assistance, contact Patient Safety and Risk Management at (800) 421-2368 or patientsafety@thedoctors.com.