Opinion ID: 2783588
Heading Depth: 3
Heading Rank: 1

Heading: Bed Sores

Text: Bed sores, also known as pressure sores, pressure ulcers or decubitus ulcers, develop when skin is exposed to prolonged external pressure that restricts blood supply, especially if the skin remains wet on an incontinent patient or is subject to shearing force from being pulled along a bedsheet. They typically form in areas of the body like the tailbone, where skin is thin, bone is close to the surface, and pressure cannot spread easily. The reduction in blood flow starves the skin tissue of oxygen and nutrients, causes the skin to thin even more, and tissue to die. Bed sores ultimately results in open wounds that can require surgery or, if untreated, can cause death. Bed sores are common in skilled nursing facilities, where many residents are bedridden. Accordingly, 42 C.F.R. § 483.25(c) requires skilled nursing facilities to ensure that – (1) A resident who enters the facility without pressure sores does not 39 Hill v. Astrue, 698 F.3d 1153, 1159 (9th Cir. 2012). 40 Thomas Jefferson Univ. v. Shalala, 512 U.S. 504, 512 (1994). 14 PLOTT NURSING HOME V. BURWELL develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.41 The Board has interpreted § 483.25(c) to mean that a facility must “go beyond merely what seems reasonable to, instead, always furnish what is necessary to prevent new sores, unless clinically unavoidable, and to treat existing ones as needed.”42 Resident Six, an 81-year-old woman, was admitted to Plott on June 28, 2007. Her diagnoses included dementia, incontinence, hypertension, depression, anemia, recurrent urinary tract infections, and a history of brain cancer. She was entirely dependent on staff, bedridden, and fed through a tube inserted into her stomach. On May 30, 2008, she was hospitalized for a methicillin-resistant staph infection (MRSA) on her scalp over her brain surgery incision. When she was readmitted to Plott on June 5, 2008, her physician prescribed the use of wrist restraints on her bed to keep her from picking at and spreading the infection in her scalp. Thus she was literally bound to her bed, on doctor’s orders, because she kept re-injuring her now-diseased scalp. She first developed bed sores on her tailbone six months after admission in December 2007. One sore formed after her 41 42 C.F.R. § 483.25(c) (emphasis added). 42 See e.g. Koester Pavilion, DAB No. 1750, at 31, 32 (2000) (emphasis added). PLOTT NURSING HOME V. BURWELL 15 admission, but before she was restrained. The sore continually healed and reopened, six times over the course of nine months.43 An additional sore appeared in September 2008 on her left buttock. Substantial evidence on the record as a whole supports the Board’s determination that Plott’s care of Resident Six violated 42 C.F.R. § 483.25(c). The Board identified specific treatments that Plott did not provide, such as specialized mattresses that help prevent bed sores. Pressure relief mattresses use high density foam, air, water, or gel to reduce and redistribute bed sore-causing pressure. More advanced mattresses reduce the risk of bed sores by alternating pressure between different areas of the body. These mattresses are called low air loss mattresses. They are powered by an air pump that provides sequential inflation and deflation or alternates pressure between the mattress’ many air cells. Despite Resident Six’s recurrent bed sores, Plott failed to timely provide two different kinds of mattresses, a pressure relief mattress and a low air loss mattress, even though they were identified by Plott’s nurses and physicians as needed interventions.44 Plott prepared a long term care plan in June 2007 when Resident Six was first admitted. The plan said that Resident Six would be provided with a pressure relief mattress. Plott’s records show that Resident Six did not receive this mattress 43 It was open from December 26, 2007 to February 29, 2008; March 13 to March 20, 2008; May 23 to May 30, 2008; June 5 to June 18, 2008; June 26 to August 1, 2008; and August 27 to September 22, 2008. 44 See Tri-Cnty. Extended Care Ctr., D.A.B. 1936, at 16 (2004) (holding that a nursing home violated § 483.25(c), in part, because it failed to provide a pressure relief mattress that had already been identified as needed in the resident’s care plan). 16 PLOTT NURSING HOME V. BURWELL until nearly a year later on June 9, 2008. An October 4, 2008 entry in her care plan says “LE [late entry] for 6/9/08 pressure relief mattress.” Based on this documentation, the Board reasonably determined that the pressure relief mattress was not timely provided. There is also substantial evidence to support the Board’s finding that this resident was later also not given the prescribed low air loss mattress until one and a half months after the prescription. An outside wound specialist assessed Resident Six’s bed sores on August 7 and August 14, 2008. Both assessments recommended that Plott “continue low air loss mattress.” Plott argues that the specialist’s recommendation to “continue use” shows that a low air loss mattress was already in use. The Board rejected that inference for several reasons. First, the care plan did not list a low air loss mattress until September 24, 2008. Second, a state surveyor from the September 2008 inspection testified that Resident Six’s mattress was Plott’s standard pressure relief mattress and it was “firm to touch.” Third, Plott’s nurse testified that Resident Six was using a pressure relief mattress at the time of the survey and that a low air loss mattress was provided “around” September 24, 2008. The Board reasonably concluded that Plott replaced the pressure relief mattress with the low air loss mattress on September 24, 2008, the last day of the survey. These reasons together suffice as substantial evidence. Plott argues that there is no evidence that the bed sores were avoidable or that it failed to successfully treat them. Though Resident Six’s bed sores healed and her medical conditions made treatment and avoidance of new sores exceedingly difficult, the regulation requires nursing facilities to “ensure” that “pressure sores do[] not develop” and that a PLOTT NURSING HOME V. BURWELL 17 “resident having pressure sores receives necessary treatment and services to . . . prevent new sores from developing.”45 The evidence sufficed under the lenient “substantial evidence” standard, in light of the delay in furnishing the prescribed mattresses, to support the Board’s determination. Likewise, the evidence sufficed for the Board’s rejection of Plott’s unavoidability defense. “[T]he facility must ensure that [] [a] resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable.”46 The Board, interprets “unavoidable” as “incapable of prevention despite appropriate measures taken in light of the clinical risks.”47 The mattress delays were sufficient evidence for rejection of this defense.48