Our Firm Is Seeing More of These Cases
The Alarming Rates of ‘Never Events’
What is a “never event”? In the early 2000s, the Centers for Medicare & Medicaid Services (CMS) began penalizing and refusing to cover the cost of care associated with medical errors that should never occur and duly titled them “never events.”
The list of “never events” — sometimes referred to as Hospital-Acquired Conditions (HAC) — has grown over the last 20-plus years. Never events include things like a surgery performed on the wrong body part (i.e., amputation of the wrong arm); patient suicide while in the care of a medical facility; a patient’s death or serious injury associated with a fall while in the care of medical professionals; a foreign body being left in a patient during surgery; or pressure ulcers acquired after admission to a medical facility.
Despite CMS’s efforts to reduce never events by penalizing health care facilities when they occur, and thereby attempting to increase patient safety, never events still happen at alarming rates.
Our firm has seen an uptick in the number cases we are consulted on regarding two particular never events — hospital acquired pressure ulcers and patients who suffer injuries due to falls while in the care of medical professionals. Pressure ulcers are also known as bedsores, pressure injuries, and decubitus ulcers. In simple terms, pressure ulcers are injuries to the skin that result from pressure being exerted on a particular area of skin for an extended period-of-time. The constant pressure depletes the amount of natural blood flow to the area, and without the oxygen and nutrients being transported by the blood, the tissue begins to become necrotic. While they can occur effectively anywhere on the body, these ulcers most commonly occur on patient’s heels, ankles, low back, tailbone, and the hips.
Patients with limited mobility are at the highest risk for developing bedsores. These patients are often the most vulnerable and include paraplegics, quadriplegics, comatose patients, and those with other medical conditions that hinder their ability to ambulate or shift positions on their own.
Pressure ulcers are categorized by stages. Pressure ulcers escalate from unstageable to Stage 1, 2, 3, and 4 based on several factors including size and depth. An unstageable bedsore may be nothing more than inflamed, unbroken skin. On the other end of the spectrum, a Stage 4 pressure ulcer can be life threating. Stage 4 ulcers are characterized by severe tissue damage that penetrates all three layers of skin. At this stage, patients may experience “tunneling” and the sore can appear like a crater, exposing muscles, tendons, and bones. As you might imagine, bacteria and other infections become a grave concern as a given bedsore progresses through the stages.
As our understanding and knowledge of this body of medicine has sharpened and expanded in recent years through litigating these cases, we have come to learn that bedsores, particularly in a medical setting, are exceedingly preventable. Most, if not all, medical facilities from big hospitals to rehab centers and nursing homes have training, policies, and procedures pertaining to bedsore prevention. Bedsores can largely be prevented or eradicated with adequate staff-assisted turning and repositioning of patients who are unable to do so themselves. This simple yet necessary action can relieve the pressure on a given area of skin and allow the patient’s blood to flow naturally. In turn, an immobile patient’s risk of developing bedsores or their bedsores escalating in stages diminishes greatly.
In facilities where low staffing levels prevent patient turning on required intervals, alternating air pressure mattress pads (which can be purchased on Amazon for well under $100) can go a long way towards preventing bedsores.
Unfortunately, these preventive measures are commonly not taken. In many cases, families of bedridden patients contact our office with concerns that their family member has been neglected by their caregivers. In many of these cases, further inquiry often unearths more troubling issues. Not only are bedsores present on many bedridden patients, but they are also often acquired in a hospital setting, and hospital records pertaining to the bedsores are usually littered with inconsistencies, errors, and omissions. Medical records in this state of discord leave hospitals in a state of defensive scramble. And rightfully so — it is difficult to defend the occurrence of a “never event” as gruesome and preventable as a bedsore.
Hospital falls, like bedsores, are never events that our firm is called on to review all too often. Patients, particularly those who are advanced in age, who are being treated in a hospital or other medical setting are under the encompassing care of the medical facility. Hospitals are expected to maintain the well-being of their patients. As part of this undertaking, hospitals and other care facilities should have fall prevention programs in place. In an ideal world, fall prevention programs should involve creating an individualized fall prevention plan for each patient. Among other things, these plans need to consider staff education and training, adequate supervision of patients, treatment of delirium, and the provision of safe footwear, use of wheelchairs, and bed rails.
Sadly, in our experience, these plans are often either not implemented properly or not created in the first place. When a fall occurs, the resulting injury or death is often the proximate cause of the medical facility’s failure to execute its fall prevention program. Again, similar to bedsores, these hospital falls are often preventable and rarely the subject of a legitimate excuse. If you or one of your friends or family members has been the victim of a never event, please reach out to our office.