Christa A. Bakos, RN, CWCN, DAPWCA, Nursing, Hospital, Home Health & Wound Care Expert

The plaintiff, an 80-year-old female, had a medical history which included dementia, Alzheimer’s, stroke with right side weakness, diabetes, hypertension, urinary incontinence, GERD, cervical disc disorder, and chronic kidney disease. She resided at home with her son, daughter-in-law, and two granddaughters.  One of the granddaughters was her designated care giver. 

On November 2, 2015, due to plaintiff’s inability to safely leave her home, in-house physician services were initiated and provided.  On April 1, 2016, a Nurse Practitioner of the in-house physician services, assessed the plaintiff and documented a sacral stage III pressure injury that measured 3 x 2 x 1.5cm. 

On May 5, 2016, home health skilled nursing services were ordered by the plaintiff’s medical provider.  Between May 5, 2016 and May 20, 2016, plaintiff’s family refused home health care services.  On May 21, 2016, skilled nursing services for the plaintiff began through a Home Health company, which consisted of visits for pressure injury care three times a week.  At the start of this care, it was documented by the home health nurse that the plaintiff had a stage III sacral/coccyx pressure injury present measuring 8 x 5 x 2.5 cm with undermining present of 1.5 cm from 1:00-4:00 and a tunnel at 9:00 measuring 3cm.

According to the documentation of the last nursing visit of June 10, 2016, the sacral pressure injury measured 8.5 x 5x 2.5 cm with undermining measuring 1.7 cm from 1:00-4:00 and a tunnel at 9:00 of 3cm. 

On June 13^th, 15^th, and 17^th the plaintiff’s family cancelled the scheduled nursing visits due to “out-of-town family visiting.” During this time the plaintiff’s granddaughter provided the pressure injury treatments. A home health nurse visit was scheduled for June 20, 2016; however, on June 19, 2016, the plaintiff was transported to the local hospital by family for change in mental status, being non-communicative, lethargic, and poor oral intake.  

Upon plaintiff’s admission to the local hospital on June 19, 2016, it was documented that she had an unstageable sacral pressure injury measuring 10 x 5 cm with an undetermined depth, with heavy, purulent, foul-smelling drainage. The periwound was boggy and macerated. The plaintiff was diagnosed with sepsis and an infected unstageable sacral ulcer, and was admitted into hospice on June 23, 2016, ultimately dying on June 26, 2016. The cause of death documented on the death certificate was sepsis related to an infected sacral pressure injury. 

The family of the plaintiff alleged that the care provided by the Home Health agency between May 5, 2016, and June 20, 2016 fell below the standards of care of nursing, increased the risk for harm, and contributed to her death. Expert nursing testimony alleged that the home health agency failed to accurately and consistently document and assess the plaintiff’s pressure injury; failed to suggest treatments for the pressure injury; failed to follow the ordered treatment plan; and, failed to provide adequate education and teaching to the patient and/or caregivers. Expert physician testimony alleged that the home health agency failed to prevent the deterioration of the pressure injury; failed to notify the physician of the deterioration of the pressure injury; failed to obtain appropriate treatment orders; failed to provide pressure relieving mattress, wheelchair cushion and heel boots; failed to assess nutritional status; and, failed to provide care such as turning/repositioning every two hours. 

Upon review of the documentation, it was determined that plaintiff’s sacral pressure injury developed while under the care of her granddaughter who was working full-time as a home health aide through another agency that was not named in the complaint. The sacral pressure injury developed and continued to deteriorate while under the care of family and prior to the involvement of the Home Health company. It was also determined that the plaintiff’s family refused care and cancelled visits leading up June 20, 2016, when she was transported to the hospital.  

Further documentation supported the fact that the Home Health company did provide education and instructions on pressure injury prevention and care. This included frequent toileting, brief/diaper changes, turning, and repositioning. It was documented that family refused to frequently change the plaintiff’s briefs/diapers because it was too difficult. The family also testified in deposition that they would have the assigned home health aide change the brief/diaper every morning. According to documentation of the Home Health company, the family stated they were not able to change the plaintiff’s briefs/diapers throughout the day because she refused and physically pushed them away.

In conclusion, it was determined that during the weekly visits performed by a home health company, the pressure injury did not increase in size or show signs or symptoms of infection. The pressure injury deteriorated after the last documented visit of June 10, 2016, and during the time family refused visits leading up to the plaintiff’s admission to the hospital on June 19, 2016.

Christa A. Bakos, RN, CWCN, DAPWCA, Nursing, Hospital, Home Health & Wound Care Expert with DJS Associates, Inc., can be reached via email at experts@forensicDJS.com or via phone at 215-659-2010.

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