Nursing home residents are often at risk for developing bedsores (also known as decubitus ulcer or pressure sores) as a result of their underlying health problems and immobility issues.  A pressure sore/decubitus ulcer is a bedsore caused by unrelieved pressure on the skin from lying or sitting in the same position too long and are associated with pain and can be deadly.   As these bedsores deteriorate and progress to stage 3 (appear as a deep crater) and to stage 4 (involve full-thickness skin loss exposing bone or muscle), they become gruesome images for family members and loved ones to view.   

Nursing home residents who have developed bedsores typically receive treatment at wound clinics or hospitals.  As part of their treatment, some wound clinics and hospitals take photographs of the condition to monitor the progress of the wounds.  In our experience, such photographs may not be mentioned in the medical records and health care providers may not produce these wound photographs in response to medical record requests unless they are specifically requested.  Our law firm therefore sends specific requests for the production of wound photographs to wound clinics and hospitals in our bedsore cases and have been able to uncover the existence of very helpful evidence. 

If a family member or loved one has developed wounds/pressure sores/decubitus ulcers, it is also advisable to take photographs of the condition and to be able to state the dates of the photographs.

As the saying goes, a picture really is worth a thousand words.

Please feel free to contact the Maryland nursing home neglect lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores/pressure sores or decubitus ulcers.

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As the United States' population grows older, more and more individuals become vulnerable and dependent upon others to meet their most basis needs forcing families to place their loved ones in nursing homes.  This can be one of the more difficult issues that families will have to face and may result in feelings of guilt and fear of potential nursing home neglect.

Many nursing homes are understaffed and/or unable to provide their residents with all of the care that they may require.  According to the United States Centers for Disease Control ("CDC"), a 1996 study found that more than 500,000 people age 60 or older were victims of neglect or abuse during a one-year period.  

There are on-line resources available to families who are trying to locate and investigate potential nursing homes or assisted living facilities for their loved ones.  The Center for Medicare & Medicaid Services (CMS) website located at www.medicare.gov/nhcompare/ allows individuals to search nursing homes by location (zip code or City and State) or by name and obtain very useful information (including staffing statistics and State surveys/deficiency notices). 

Additionally, Maryland assisted living facility deficiencies are available on-line at the Maryland Health Care Commission's website located at mhcc.maryland.gov/consumerinfo/longtermcare/searchpage.aspx.  

Family members should make efforts to be advocates for their loved ones throughout the process of choosing a long term care facility and should then continue to stay involved and make regular nursing home visits at unpredictable times.  In our experience, the nursing home staff is able to figure out when a resident does not receive visitors, and the consequences can be fatal. 

For instance, we handled a case involving an elderly woman who required assistance with all activities of daily life and was placed into a nursing home.  Her children had busy and hectic lives, and very rarely visited the nursing home.  One day, she was found non-responsive and transported to the hospital where she was diagnosed with respiratory failure, severe electrolyte imbalances, metabolic acidosis, and multi-organ failure all secondary to massive dehydration and malnutrition.  Disturbingly, oral examination revealed that her mouth was filled with dried food and purulent secretions as food was being haphazardly stuffed into her mouth by the nursing home staff.  She died three days later due to dehydration and malnutrition.  Our medical expert witnesses concluded that this condition was the result of severe water and food deprivation occurring over an extended time period.  

Please feel free to contact the Maryland nursing home neglect attorneys at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of dehydration, malnutrition, bedsores (also known as pressure sores or decubitus ulcers), nursing home falls, medication error/prescription mistake, elder abuse or elder neglect.

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Staffing levels should be the subject of discovery in nursing home negligence cases.  Studies have suggested that 90% of nursing homes are understaffed.  Such staffing shortages create the potential for serious injury (or even death) to nursing home residents. 

For instance, many immobile nursing home residents require turning and repositioning at least every two hours by the nursing home staff in order to relieve pressure.  Failure to receive such care may result in the resident developing otherwise avoidable decubitus ulcers (also known as pressure sores).  Understaffed nursing homes are less likely to regularly provide such necessary pressure relief and may increase the chances that residents go on to develop potentially fatal bedsores.

In our cases, we routinely engage in discovery aimed at obtaining information regarding the target nursing home's staffing levels during the time period of the alleged negligent conduct.  We start by propounding Request for Production of Documents requesting the following:

1. All documents in Defendant's possession concerning or relating to staffing and/or staffing numbers and/or staffing levels at [insert name of nursing home] during the period of _____ through _____ including but not limited to staffing sheets.

2. All documents in your possession from the period_____ through _____ that in any way mention or discuss staffing shortages and/or the need to hire additional staff to care for patients at [insert name of nursing home].

3. All documents that discuss or pertain to Defendant's procedures, guidelines or policies concerning staffing, staffing numbers and staffing levels at [insert name of nursing home] during the period of _____  through _____.

4. Copies of all inspection reports or evaluations generated concerning or involving [insert name of Plaintiff] by any federal or state government agencies that regulated or monitored [insert name of nursing home].

5. Copies of any citations, warnings, reprimands, or violation notices received by [insert name of nursing home] concerning or involving [insert name of Plaintiff].

Sometimes, it may be necessary to seek Court intervention and/or take depositions of corporate designee witnesses in order to ensure that the nursing home timely produces these materials.  Once received, we provide these documents to Plaintiffs' medical expert witnesses so that staffing issues can be analyzed.

Please feel free to contact the nursing home neglect attorneys at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a nursing home neglect, bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, or medication administration error/prescription mistakes.

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Placing a family member or loved one in a nursing home or assisted living facility is a very difficult decision.  Nursing home residents typically require assistance with many activities of daily living and require careful monitoring and attention by the facility's staff.  These vulnerable nursing home residents are at risk for serious injury if they do not receive proper and adequate care.  For instance, nursing home residents may suffer serious life-threatening injuries resulting from falls, bedsores, medication errors or failures to monitor the resident.       

Most physicians would agree that the minimal standards of care applicable to such nursing homes facilities is:
(1) to ensure that a resident entering the facility without pressure ulcers does not develop them unless the resident's clinical condition demonstrates that they were medically unavoidable;
(2) to prevent the resident from experiencing falls, including but not limited to the development and implementation of fall prevention mechanisms;
(3) to develop, document, implement and monitor the efficacy of a comprehensive care plan to achieve the highest practical physical, mental and psychosocial well-being consistent with the resident's condition and advance directives and revise the care plan as needed;
(4) to perform a comprehensive assessment of the resident's physical, mental, and psychosocial needs on initial admission and any subsequent admissions;
(5) to maintain an accurate and complete clinical record that reflects (a) the care and treatment provided to the resident; (b) the resident's current condition and any changes in the clinical condition; (c) any responses to interventions; and (d) a record of communication between the physician and the facility staff regarding the resident's condition and care and treatment plan;
(6) to promptly and thoroughly assess all changes in the resident's physical, mental and psychosocial condition, and communicate such changes to the attending physician;
(7) to implement any care and treatment ordered by the attending physician;
(8) to ensure that all significant, non-emergent changes in the resident's physical, mental and psychosocial condition are promptly communicated to the physician;
(9) to maintain an accurate and complete clinical record that reflects (a) the care and treatment provided to the resident; (b) the resident's current condition and any changes in the clinical condition; (c) any responses to interventions; and (d) a record of communication between the physician and the facility staff regarding the resident's condition and care and treatment plan;
(10) to follow up and report diagnostic study reports to the attending physician in a timely manner.


Patients residing at nursing homes are often at risk of developing pressure sores/decubitus ulcers as a result of their underlying health problems and immobility issues.  A pressure sore/decubitis ulcer is a bedsore that comes from lying in the same position too long and is associated with pain. 

Nursing home patients experience pressure from the bed and/or chair to certain points on their skin preventing the blood from flowing into those points.  Because the blood is not allowed to flow into those points, the skin, deprived of nutrients and oxygen, can become injured and susceptible to infection.

Pressure is a primary contributing factor to the development of pressure ulcers.  Since the development of pressure ulcers depends on the length of time pressure is applied, immobility is the major risk factor.  Pressure must be relieved.  Malnutrition and adequate hydration have been linked to the development of pressure ulcers. 

A stage one ulcer presents as redness of the skin and represents tissue injury and heralds skin ulceration.  A stage one ulcer is classified as nonblanchable erythema with intact skin.  Erythema is redness of the skin produced by congestion of the capillaries.  Erythema is the initial reactive hyperemia caused by pressure, and nonblanchable erythemia represents s stage one pressure ulcer.

A stage two ulcer is characterized by partial-thickness skin loss, that is, the epidermis is interrupted as an abrasion, blister or shallow crater.

A stage three ulcer features full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend to, but not through, the underlying fascia.  The ulcer appears as a crater, with or without undermining of adjacent tissue.

A stage four ulcer involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., a tendon or a joint capsule).

With stage 3 or 4 pressure ulcers, the extent of the disease may not be evident because of covering necrotic material or eschar.  To establish the extent of the disease and promote healing, the necrotic material needs to be removed and surgical consultation may be required.  When ulcers develop over bony prominences, osteomyelitis is a potential complication.  Pressure ulcers are chronically contaminated wounds and the combination of bacteremia and pressure sores can be painful and life threatening.

Ultimately, pressure ulcers are avoidable so long as proper care and preventative measures are instituted and implemented by the nursing home.  In fact, under new Medicare guidelines, hospitals are no longer reimbursed for additional care resulting from bed sores and several other "reasonably preventable" errors including objects left in the body after surgery. The government has determined that development of bedsores at a hospital is a so-called "never event."

Please feel free to contact the nursing home neglect attorneys at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication error/prescription mistake, elder abuse or elder neglect.

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A decubitus ulcer/pressure sore is a bed sore caused by unrelieved pressure on the skin that comes from lying or sitting in the same position too long and is associated with pain.   
Unfortunately, once a bedsore progresses to stage 3 and stage 4 and becomes infected, it is difficult to achieve healing and avoid painful and potentially fatal complications.  These individuals may develop osteomyelitis (infection of the bone) and/or sepsis (blood infection) ultimately resulting in death. 

Nursing homes develop and implement internal policies and procedures pertaining to the prevention, care, treatment and monitoring of pressure sores /decubitus ulcers.  For instance, such policies and procedures generally require that the nursing home staff must relieve pressure by turning and repositioning residents at least every two hours while in bed and every hour while in a Geri-chair or wheelchair.

Under Maryland law, such policies and procedures may be admissible at trial as evidence of the applicable standard of care in nursing home/bedsore negligence cases.  See Wilson v. Morris, 317 Md. 284 (1989) (finding that  a Day Care Center's patient monitoring policy was admissible evidence that was relevant to the jury's consideration of the appropriate standard of care).

It is therefore imperative that Plaintiffs' attorneys request and receive all relevant policies and procedures from defense counsel in the very early stages of litigation through the use of detailed Request for Production of Documents.  (We regularly serve Defendants with such discovery requests along with the Complaint and initial pleading materials).  Sometimes, it may be necessary to seek Court intervention and/or take depositions of corporate designee witnesses in order to ensure that the nursing home timely produces these materials.  Once received, these policies and procedures should be provided to Plaintiffs' medical expert witnesses in order to assess whether the nursing home followed their own policies and procedures and protocol.  The failure of a nursing home to adhere to their own policies and procedures is important evidence that will be taken into consideration when the nursing home's attorneys and in-house representatives evaluate the claim.  This is also very powerful evidence that can be presented to the jury.

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Please feel free to contact the nursing home neglect lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication administration error/prescription mistake, elder abuse or elder neglect.

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Older adults in nursing homes may require feeding tubes for a variety of reasons including swallowing difficulties and as a precautionary measure to attempt to prevent aspiration pneumonia in certain types of patients.  These feedings tubes can be temporary or permanent and require close monitoring in order to avoid potentially life threatening complications.  Gastrostomy feeding tubes (G-tubes) involve the placement of a feeding tube through the stomach wall directly into the stomach; Jejunostomy feeding tubes (J-tubes) involve the placement of a feeding tube through the abdomen into the small intestine; Nasogastric feeding tubes (NG-tubes) involve the placement of a feeding tube through the nose and esophagus and into the stomach.

Some complications to watch for include clogged tubes (especially if the feeding tube is not properly maintained and cleaned), dislodged tubes and infection around the tube insertion area.  It is very important that the nursing home staff carefully monitor tube feedings and notify physicians of significant changes in the patient's condition.  Additionally, in the event that a Jejunostomy tube (J-tube) becomes dislodged, nurses should notify the physician immediately and should not attempt to reinsert the feeding tube on their own.  Rather, this should generally be performed by a physician in a hospital setting.

Please feel free to contact the nursing home neglect lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of feeding tube complications, bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication error/prescription mistake, elder abuse or elder neglect.

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Dehydration is a serious medical condition that occurs when the amount of water leaving the body is greater than the amount being taken in.  Dehydration is common in elderly people as a result of physiological changes in the body resulting in loss of protein which holds water, decrease of kidney urine concentrating abilities resulting in frequent urination, and decreasing thirst.  Many medications, including blood pressure medication, anti-depressants and laxatives, also cause dehydration. 

Dehydration often goes undiagnosed and untreated in elderly nursing home patients.  Fluid volume deficits can have devastating consequences such as causing kidney failure, seizures, swelling of the brain, hypovolemic shock, and increases a resident's susceptibility to urinary tract infections in females.  Ultimately, dehydrated nursing home residents may develop sepsis resulting in death because their ability to fight infections has been compromised.   

The standard of care for residents in nursing homes requires the nursing home staff to provide each resident with sufficient fluid intake to maintain proper hydration and health.  Nursing homes should develop, implement and (when needed) revise care plans to protect residents from fluid volume deficits and water deprivation.  Fortunately, the potentially fatal consequences of dehydration can be prevented if the nursing home staff takes preventative actions including recording daily food and fluid intake, monitoring body weight on a daily basis and implementing a hydration program that provides water during and between meals.  The nursing home must carefully and thoroughly monitor fluid and nutritional support and initiate appropriate treatment when intake falls below adequate levels.

Please feel free to contact the nursing home neglect attorneys at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of dehydration/malnutrition, bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, medication error/prescription mistake, elder abuse or elder neglect.

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Every year, many nursing home patients are hospitalized due to adverse drug reactions. The multiple medications that are often prescribed to these elderly patients increase their risk for this type of complication. Adverse drug reactions are commonly seen with anticholinergic drugs, sedative-hypnotic drugs, and neuroleptic drugs, especially when prescribed concurrently.

Careful monitoring of the patient's condition and review of their medical history is necessary to avoid an adverse drug reaction. Problems may occur when a patient's medication regimen is altered without careful review of current medications, or perhaps an older medication is continued when it is no longer needed. Sometimes old prescriptions are re-prescribed without being evaluated. It is also important that PRN ("as needed") orders are written with full instructions and that those instructions are followed.

When prescribing medication, the patient's age, weight, and gender should be considered. Older adults generally weigh less and have an increased sensitivity to drugs due to decreased liver and kidney function. Dosage should be altered accordingly.

Please feel free to contact the nursing home neglect lawyers at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of an adverse drug reaction, medication error or prescription mistake.

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More nursing homes have implemented electronic medical record systems and this trend will certainly continue as the cost decreases, technology improves and financial incentives in the form of higher reimbursement rates for treating Medicare patients are offered. 

Lawyers handling nursing home negligence cases must be sure to update their form discovery requests to make sure that certain types are electronic/computerized records are specifically requested or they risk exclusion of potentially helpful evidence of negligence. 

For instance, in litigating bedsore cases (also known as pressure sores or decubitus ulcers), we have encountered situations with nursing homes that utilize a computer/kiosk record keeping system requiring the nursing home geriatric nursing assistants who provide care (including turning and repositioning) to the patient to make an entry in a computer kiosk each and every time the patient is turned and repositioned.  In the event that such records do not document that the patient was turned and repositioned every two hours, this can be powerful evidence of negligence. 

Unfortunately, these electronic records may not always physically make their way into a patient's chart.  It is possible that nursing homes and their lawyers may try to read Plaintiffs' discovery requests narrowly to support a decision not to produce these records if they are not specifically requested. 

Our firm therefore includes the following Request in Plaintiffs' Request for Production of Documents in bedsore/pressure sore/decubitus ulcer nursing home negligence cases:

A complete copy of all of Defendant's files regarding Plaintiff including but not limited to medical records, nursing home admission records, computer records, electronic records, kiosk records, log records or other documents containing written or computer entries regarding Plaintiff made by geriatric nursing assistants, certified nursing assistants or other nursing assistants that were/are maintained separately from Plaintiff's medical records at [insert name of nursing home].

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Please feel free to contact the nursing home neglect attorneys at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of bed sores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition, medication administration error/prescription mistake, elder abuse or elder neglect.

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Nursing homes may attempt to include arbitration agreements among the stack of paperwork that they have patients or their families sign at the time of admission to the facility.  These arbitration agreements attempt to prevent jury trials in the event of subsequent lawsuits alleging injuries or death resulting from nursing home negligence. Instead, such disputes would be decided by arbitrators who are often chosen by the nursing home and subject to rules and procedures dictated by the nursing home.

Many people have no idea what they are signing at this very stressful time in their lives when they are focused on ensuring that their family member or loved one receives all necessary medical care.  As a result, family members may sign these arbitration agreements that have been carefully drafted by the nursing home's lawyers without even reading the documents and/or giving any thought whatsoever as to later ramifications. 

On or about May 12, 2011, Senators Al Franken (Democrat-Minnesota), Richard Blumenthal (Democrat-Connecticut) and Representative Henry Johnson (Democrat-Georgia) introduced identical bills in the United States Senate and House of Representatives known as the "Arbitration Fairness Act of 2011" that, if enacted, would (among other things) ban forced arbitration clauses in nursing home admission contracts.  The legislative process of this bill is still in the relatively early stages but given the present congressional make-up passage seems unlikely at least until the 2012 election cycle ends. 

Executed nursing home arbitration agreements typically are not even a precondition to the patient receiving treatment or services.  Hopefully, these forced arbitration clauses will be eliminated by Congress at some point in the future so that nursing home consumers and their surviving family members cannot be denied their day in Court.  
In the meantime, however, families should be careful not to sign such arbitration agreements even though these clauses may be hidden in fine print and difficult to understand. 

Please feel free to contact the nursing home neglect attorneys at Dever & Feldstein, LLC at (888) 825-9119 for a free consultation if you believe that a family member or loved one has sustained serious injury or wrongful death as a result of nursing home neglect including bedsores (also known as pressure sores or decubitus ulcers), nursing home falls, dehydration/malnutrition or medication error/prescription mistakes.

 

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