Make your case with medical records about pressures ulcers. Pressure ulcer staging and correct documentation are critical in acute care settings as well as long-term care settings. What the nurse assessed and documented is key to winning your client’s case.

Pressure ulcers, a.k.a. decubitus ulcers or bed sores are caused by unrelieved pressure. Any bony prominence is at the highest risk. Patients who are immobile for periods of time, as on an operating room table or unable to turn and reposition themselves are at the highest risk for developing pressure ulcers.

Staging Pressure Ulcers

After a pressure ulcer has been assessed it is essential that the correct stage of pressure ulcer is assigned and documented. Here are a few essential do’s and don’t of pressure ulcer staging.

• Pressure ulcers are assessed as Stage 1, 2, 3, 4, Unstageable and Deep Tissue Injury. Documentation must accurately reflect each stage.
• The higher the stage the more underlying tissue damage there is.
• Once a pressure ulcer is “staged” it can progress to a higher stage but can NEVER be “BACK-STAGED REVERSE STAGED or DOWN STAGED”. Example: A Stage 3 pressure ulcer can worsen and become a Stage 4 but it NEVER becomes a Stage 2 as it heals. If a health care provider documented using back staging, this reflects that the clinician assessing the wound did not have a thorough grasp of the appropriate rules of pressure ulcer staging as set forth by the National Pressure Ulcer Advisory Panel (NPUAP).
• The stages of pressure ulcer are indicative of the amount of tissue damage.

Pressure Ulcer Stages 1, 2, 3 and 4

• A stage I pressure ulcer has redness on the surface of the skin that does not disappear when pressure is relieved.
• A stage 2 ulcer is a partial thickness wound. This means there is damage to the epidermis (top layer of skin) and the dermis (the layer under the epidermis). Both of these are superficial or shallow wounds. As they heal there is no scar tissue formation and the tissues damaged will regenerate as healing takes place. This is one of the reasons it is so important for the healthcare team to correctly treat pressure ulcers to reduce the risk of them progressing to more involved wounds.
• Stages 3 and 4 are full thickness wounds, which are much worse.
• Stage 3 is injury into the subcutaneous tissue (below the dermis) but not through to the underlying structures, i.e. the muscle, bone and/or tendon.
• Stage 4 is an injury that is very deep and muscle, bone and/or tendon will be exposed in the wound bed. Full thickness pressure ulcers are deeper and heal by scar tissue formation. There is no regeneration of the underlying tissues. The development of these ulcers gets the most attention from attorneys and their experts. The damages are significant.

Key Points to Remember about Pressure Ulcers

• Staging refers to the amount of tissue that was damaged. In the case of a Stage 4 pressure ulcer, there is damage to the underlying structures that will never regenerate with the type of tissue that was damaged. Scar tissue is not as strong as healthy tissue and is more likely to break down again.
• If there is scarring on a patient’s body, it has to have come from a Stage 3 or 4 pressure ulcer!
• If documentation stated that the wound is a Stage 3 and muscle is documented as assessed in the wound bed, it is not a correct assessment. That description is indicative of a Stage 4 pressure ulcer.
• If the documentation stated that Stage 4 is healing and now presents as a Stage 2, that is inappropriate staging. A full thickness wound never becomes a partial thickness wound.
• Slough and eschar (types of dead tissue) will only form in full thickness wounds, not partial thickness wounds. If the wound was a Stage 2 and had slough or eschar present, it was inappropriately assessed as a Stage 2. It should have been staged as a Stage 3 or 4.
• Unstageable pressure ulcers and Deep Tissue Injury (DTI) pressure ulcers have been considered as additional pressure ulcer stages by the NPUAP since 2007.

Has anyone found that the documentation is the key to a successful case or the downfall of the case?

Med League provides medical expert witnesses to trial lawyers. Please call us at (908)788-8227 or contact us today to discuss your next case.