A nursing home administration expert witness advises on a case involving an elderly female patient who on August 14, 2014, fractured her pelvis. A pelvic x-ray revealed a left parasymphysis pubis fracture not involving the acetabulum. She was hospitalized as an inpatient on August 18, 2014. On August 22nd, she had her first physical therapy session in the Delaware hospital. During therapy she put little weight on her left lower extremity due to pain, yet she performed ankle pumps, hip abduction and adduction, long arc quads and marching for 5-10 repetitions. Physical therapy would consist of gait training, bed mobility, transfer training, balance training and therapeutic exercise. The patient was significantly limited due to pain in her left groin and required minimum to moderate assistance for transfers with little ambulation due to painful weight bearing. The therapist felt the patient would benefit from continued physical therapy services and recommended rehabilitation at a skilled nursing facility prior to discharge home. On August 31st, the patient was transferred to a nursing home where she relied on staff for assistance with bed mobility, transfers, toilet use and personal hygiene. Shortly after admission, she described pain in her hips at 10/10 on the pain scale and was given Morphine Sulfate. While a resident at the nursing facility, she was often left in her bed for hours at a time in excruciating pain. At times, the sheets on her bed were tucked in at the edge of her bed so that her ankles and feet were pressed downward and inward for extended periods of time. The patient developed a sacral coccygeal decubitus ulcer and severe bilateral plantar flexion contractures.
Question(s) For Expert Witness
- 1. Do you routinely treat patients similar to the one described in the case?
- 2. How/when do you determine if the necessary care and services include physical therapy and re-positioning?
- 3. Have you ever had a patient develop the outcome described in the case?
- 4. Do you believe this patient may have had a better outcome if the care rendered had been different?
- 5. Have you ever served as an expert witness on a case similar to the one described above?
Expert Witness Response E-009272
I have an active academic geriatric medicine and palliative medicine practice, and I see patients in inpatient, nursing home, and outpatient clinic settings. Patients with problems similar to the patient described in this case are not uncommon in my practice. In general, frail older patients with pelvic fractures who are appropriate for rehabilitation based on their care goals (which appears to have been the situation in this case) would typically undergo post-acute rehabilitation in a skilled nursing facility including physical and occupational therapy, along with re-positioning by facility staff as needed either for comfort or for impaired bed mobility. Patients who exhibit marked impairment of bed mobility and limited mobility due to pain would be at increased risk for complications of immobility and a failed course of rehabilitation and should be identified and case-managed accordingly. I have cared for patients who don’t do well after a serious injury and who eventually develop complications of immobility such as pressure sores. The bad outcome of pressure sores doesn’t necessarily indicate poor care (although it certainly could result from poor care), but the development of pressure sores in a low risk nursing home patient (e.g., one who is initially mobile, cognitively intact, and well nourished) is considered a marker of poor care. What is important is to identify potential risk factors for pressure sores as early as possible, to develop a comprehensive, interdisciplinary care plan to mitigate these risks as much as possible, and to modify the plan as needed for changing circumstances. A careful chart review can often identify whether an appropriate care planning process was in place.