A care plan in a hospital is a structured, individualized roadmap that outlines a patient’s specific health conditions, goals, and the medical or supportive interventions needed to address them. The primary functions of a care plan involve centralized communications, coordination of care, patient-centered focus, measurable goals, and preparation for an eventual discharge.
Failing to update a patient’s care plan is dangerous because it can result in mismatched, unsafe, or delayed treatment that directly threatens patient health and safety. Not only can it cause physical and wound neglect, but patients can also receive inconsistent or fragmented care that does not align with their medical needs.
When someone we love enters the hospital, we trust the medical team to watch closely, notice changes, and adjust treatment when something goes wrong. In this case, that trust was broken. A care plan that stays the same while a patient’s condition deteriorates is the central failure in this case, because the entire purpose of the plan is to adapt to the patient’s needs. As our client’s situation shifted dramatically, the roadmap never moved.
Our firm represented the family of a man whose health steadily declined across several hospital stays while his nursing staff kept the same plan of care in place. He did not survive. The case was resolved with a settlement of over $475,000.
A Care Plan Is Supposed to Change as the Patient Changes
Our client was taken to the hospital because of involuntary jerking movements. In the weeks before, he had also lost his appetite and was dealing with diarrhea, urinary incontinence, weight loss, and fatigue. Even so, he was awake, alert, and oriented, and his mental status was normal. A CT scan showed a possible small subdural hematoma, which is a collection of blood between the brain and its outer covering. He was moved to the emergency department and admitted to the intensive care unit.
Upon admission, a nurse assessed his risk of skin breakdown using the Braden Scale. Hospitals use this standard tool to predict which patients are likely to develop pressure injuries, commonly called bedsores. He scored a 17, which falls within the mild risk range of 15 to 18.
The admitting nurse also noted a ruptured blister on his right heel and redness on his upper back and buttocks. The hospital’s own protocol called for turning and repositioning him every two hours, protecting his heels and other bony areas, and managing moisture and nutrition. From his first day, the staff had a documented reason to protect his skin.
His overall condition then slipped. He became moderately malnourished. He developed abnormal posture, poor balance and coordination, and impaired safety awareness. He had trouble moving in bed, transferring in and out of bed, and walking, and he lost strength, endurance, and sound judgment. Doctors also diagnosed acute delirium, a sudden state of confusion, caused by the abrupt stop of a prescription medication called Lyrica. Further imaging later showed he did not have subdural hematoma after all, and no surgery was needed.
Poor nutrition, limited movement, and confusion each make a patient more vulnerable to skin wounds and infection. Together, these changes called for closer attention and a new approach to his care.
Here, the nursing staff failed to properly evaluate, assess, monitor, manage, and treat our client, and they never updated his plan of care as his condition deteriorated.
The records show no turning schedule was put in place. Despite his weakened body and confused mind, staff charted that he could reposition himself, and he was left lying on his back in bed or sitting in a chair. New complications followed.
He suffered an acute kidney injury and an E. Coli urinary tract infection. He experienced nausea, vomiting, and worsening diarrhea with abdominal cramping, and he lost control of both his bladder and his bowels. He also developed a Stage 2 pressure ulcer on his sacrum, at the base of his spine.
Serious Pressure Wounds were Documented as a Simple Rash
A full wound assessment was not completed until the day he was transferred to the hospital’s behavioral health unit. That assessment found Stage 2 pressure injuries on both heels. A Stage 2 pressure ulcer is an open wound where the skin has broken through its outer layer.
These wounds need prompt, targeted treatment to keep them from deepening. Instead, the wound care nurse recorded only contact dermatitis, a surface skin irritation, on his buttocks and treated it with a topical barrier paste.
The documentation did not match the injury, and because the wound was labeled as something minor, it was managed as something minor. The gap between what the wound was and what the record said it was, is exactly the kind of failure that allows a preventable injury to progress.
The Wrong Lab Test Sent Him Home With an Untreated Infection
In the behavioral health unit, our client complained of rectal pain and told the consulting physician he did not remember being treated for the wound on his sacrum. The physician noted the wound and requested a wound care consult, but the records show no follow-up during that stay.
Meanwhile, his diarrhea continued, and staff collected a watery stool sample. The sample should have been tested for C. diff (Clostridioides difficile), a bacterial infection of the colon that causes severe diarrhea and can become life threatening, but the nursing staff ordered the wrong test, and the sample was never checked for C. diff.
He was sent home with worsening diarrhea. Without the correct test, an infection that needed urgent treatment went unconfirmed. Four days later, he returned to the hospital with worsening diarrhea and weakness. Doctors found acute sigmoid diverticulitis, which is inflammation of small pouches in the lower part of the colon. They also found leukocytosis, a high white blood cell count that signals the body is fighting infection, along with acute kidney failure caused by dehydration. Most serious of all, he was in septic shock from a severe C. diff infection. Septic shock occurs when an infection overwhelms the body, causing blood pressure to drop and organs to fail.
He was admitted to the intensive care unit, and once again the nursing staff did not update his plan of care, implement a turning schedule, or properly secure and monitor his Foley catheter. Within about a week, the wound on his tailbone had worsened to at least Stage 3, and the wound on his left heel had become unstageable, meaning it was too deep or covered to measure.
Our client also developed two device-related pressure injuries to his genitals from the Foley catheter. Device-related pressure injuries form when medical equipment presses against the skin for too long without being checked or repositioned. Because of those injuries, doctors had to place a catheter through his lower abdomen, and he later received a feeding tube.
After the hospital, he moved to a long-term acute care facility, then to a rehabilitation facility, and then to a skilled nursing facility. He spent nearly a year working to overcome his injuries and suffered repeated urinary tract infections along the way. Despite that effort, he never recovered and passed away. His family lost him after months of suffering that began with a hospital admission in which he was alert, oriented, and able to speak for himself.
A Chain of Missed Chances, Not a Single Mistake
Hospital staff knew at admission that his skin was at risk, yet no turning schedule was put in place, and his pressure wounds were documented as a rash. His nutrition, mobility, and mental state declined, yet no one revised his plan of care. A suspected C. diff infection was checked with the wrong test, and he went home untreated. When he came back in septic shock, his wounds deepened and an unmonitored catheter caused new injuries. Each failure made the next problem harder to treat, and together they turned a man who walked in alert and talking into a patient who could not recover.
Proving a case like this requires a careful review of the nursing notes, risk assessments, wound documentation, lab orders, and discharge records, because those records show what the care team knew, when they knew it, and whether they acted. That review is what allowed this family to hold the providers accountable and seek justice for their family member who was harmed.
