When a patient is admitted into a nursing unit with debility and decreased mobility, care centers on preventing complications of immobility, promoting independence, and ensuring safety. Staff must implement proactive, multi-disciplinary care plans to reduce risks like pressure injuries, blood clots, and functional decline.
Patients with these problems are at high risk for injuries due to falls, skin breakdown, and other physiological and psychosocial complications. Specific protocols exist to assist these patients and make them as comfortable as possible while nurses care for them.
If a patient develops a pressure sore, prompt treatment is critical. Pressure sores can worsen rapidly, resist simple cures, and cause life-threatening complications. Nursing staff must be diligent and attentive with every patient at risk.
Pressure ulcers, also called bedsores, form when constant pressure cuts off blood flow to the skin and the tissue beneath it. A deep tissue pressure injury damages the tissue well below the surface of the skin. Debridement is the surgical removal of that dead tissue so the wound can heal. Most pressure ulcers are preventable with consistent repositioning, regular skin checks, pressure-relieving surfaces, and good nutrition.
In this case, our client entered a skilled nursing unit to regain her strength and mobility. Over the following months, failed assessments, discontinued medications, and an untreated wound, pushed her into malnutrition, infection, and sepsis. She died after struggling to recover from her injuries.
Our firm represented her family, and the case was resolved in a settlement of over $600,000.
Her admission called for careful screening that never happened
Our client was admitted for debility and decreased mobility. She also had a history of psychosis, depression, and sleep apnea. Those conditions required staff to plan their care around both her physical and mental health needs.
Her medical records show that her psychosis diagnosis was disregarded. Staff also failed to properly perform their risk assessment for pressure sores or to implement the interventions that assessment called for. A risk assessment is the foundation of a care plan. The assessment tells nurses and aides which residents are most likely to fall, develop pressure wounds, lose weight, or decline. When that assessment is wrong or ignored, every decision built on the assessment suffers.
Her care plan called for screening and treatment by a physical therapist and an occupational therapist, along with restorative nursing therapy. Her records do not show that she received that care. For a patient admitted because she could not move well, therapy was the core of her treatment. Without therapy, she stayed largely immobile. Immobility is one of the leading causes of pressure injuries.
Stopping her medications without a plan set off her decline – a cascading effect
Her physician discontinued the medications that treated her psychosis and sleep apnea. Her clinical, physical, mental, and functional status then declined significantly.
Warning signs followed. She withdrew from interaction, refused to eat, and stopped participating in her own care. Staff either never reported this decline to her physician or the physician disregarded the reports. Her ability to perform her normal daily activities dropped sharply, and no one documented why that loss was unavoidable.
She lost 37 pounds and became malnourished. No one considered medication to improve her appetite until she had already lost 20 pounds. Because no one properly evaluated her mental status, the weight loss continued. Poor nutrition slows wound healing and weakens the immune system. Her weight loss left her more vulnerable to every complication that followed.
Staff never turned or repositioned her. The pressure on her sacral area (the base of the spine) progressed to a deep tissue pressure injury that required surgical debridement. On one occasion, staff found her lying on her back when her orders said she should not be.
She also suffered a fecal impaction and recurrent urinary tract infections. A urinary tract infection progressed to sepsis, and she required hospital admission. Sepsis is the body’s extreme reaction to an infection. Without fast treatment, sepsis can damage organs and cause death.
The hospital transfer exposed what the nursing unit’s records missed
Her hospital charting did not match her actual condition. Staff noted one day that she had no skin breakdown, and the very next day they observed a stage two pressure ulcer. That gap raised serious questions about how closely staff had been checking her skin, and whether her records reflected reality.
In the emergency room, no one diagnosed her with sepsis. Sepsis is a medical emergency that requires prompt recognition, and proper testing would have confirmed it. Instead, she remained in the emergency room for an extended period without a hospital bed. Given the severity of her condition, she should have been admitted directly to the ICU. Her physicians failed to review abnormal lab value and update her plan of care. Emergency nursing staff failed to monitor the breakdown of her sacrum and failed to notify the physician of abnormal findings.
Her care broke down again at shift change. The outgoing physician did not communicate her condition to the incoming physician, and neither physician documented an assessment of her.
Staff also failed to follow routine orders and never monitored her IV site for changes. She then developed a DVT (deep vein thrombosis), a blood clot in a deep vein. Proper monitoring would have allowed timely treatment of the clot. Poor documentation also delayed treatment of her seizures, which worsened her mental status.
Families can spot many warning signs early
No one told her family about her pressure sores or her worsening condition. Families are often the patient’s strongest advocates. Without information, her family could not ask questions, request a care conference, or push for a transfer while there was still time to change her course.
Each failure in this case left visible signs. If a loved one is in a nursing home or hospital, watch for:
- Redness, open skin, or odor around the tailbone, buttocks, hips, or heels
- Noticeable weight loss or a sharp drop in appetite
- New changes in speech, alertness, mood, or willingness to accept care
- Medications stopped or changed without explanation
- Little or no therapy for a patient admitted for rehabilitation
- Repeated infections, fever, or sudden confusion
- Staff who cannot or will not answer questions about your loved one’s condition
Our client’s story shows how a chain of failures in a nursing facility and a hospital can cause an otherwise preventable death. It also shows families what to watch for when a loved one is admitted for care.
