Hospital Fined By State For Poor Patient Care Resulting in Bed Sore

A state has fined a hospital after state health investigators confirmed that substandard postsurgical care resulted in a patient developing a bed sore (pressure sore, pressure ulcer, decubitus ulcer).

The investigation by the state Bureau of Health Care Quality and Compliance in March sustained the complaint that the patient, who had double-knee replacement surgery, received little help from hospital staff while in bed with both legs immobilized. The report also confirmed he was not instructed in the use of the trapeze above his bed that would have helped him change his position.

The hospital said patient care involves a human element, and “occasionally a process is not followed through. When we discover a situation where care was less than ideal, we always take the opportunity to review the case and retrain and coach staff on expectations ...

The state health report indicates that standard preventive practices weren’t followed in the case of the knee replacement patient treated in November 2008. The patient, who the hospital said was known to be a high-risk for bed sores, reported that it was difficult to summon a nurse, he did not receive help with bathing or moving his position and was unable to turn himself on his back.

State investigators quoted an interview with the patient’s wife in which she said: “the nursing care was poor, the urinal sat on a tray and never got emptied, and he never got a shower… It was hard to get anybody to help with anything.”

The report rated the severity of the case as a 3 on a scale of 4, meaning some injury was recorded but not fatal or very serious injury. It noted that only one patient was affected by the lapse in care.

Bed sores, also called pressure ulcers, are areas of tissue death that result when blood flow has been interrupted by unrelieved pressure for a prolonged period according to medical dictionaries. In severe cases, pressure ulcers can eat to the bone and result in serious infection.

Medical experts said bed sores almost always are preventable and often are a sign of neglect in hospitals, nursing homes and assisted-living facilities. National figures suggest that a minimum of 2.5 percent of hospital patients may develop bed sores as compared to 10 percent or more of nursing home patients.

As of 2008, the federal Medicare program no longer paid hospitals to treat pressure ulcers acquired while patients were under treatment. Some private insurers are following Medicare’s lead and refusing to pay hospitals for facility acquired pressure ulcers, according to the American Hospital Association. For more, read the story.


Robert W. Carter, Jr. is a Virginia attorney whose law practice is dedicated to protecting the rights of the victims of nursing home and assisted living neglect and abuse in Richmond, Roanoke, Norfolk, Lynchburg, Danville, Charlottesville, and across Virginia. 


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