Examples of How Pressure Injury Incidents Can Lead to Fraud, Waste, and Abuse
Jeannine LeCompte, Compliance Research Specialist
The failure to properly prevent and treat pressure injuries in a Skilled Nursing Facility (SNF) environment can lead to Office of Inspector General (OIG) charges under the fraud, waste, and abuse categories of the Public Health Act, and facility administrators should be aware of the specific circumstances under which their institutions can be held liable.
The following case studies provide examples:
* Two California SNFs were fined $160,000 by the state for resident care and staffing violations in 2016, following the deaths of two residents who had developed severe pressure ulcers which became infected. They are currently the subject of a major civil lawsuit which claims that the two residents died from “entirely avoidable” ulcers caused when “patients are not moved regularly by nursing staff.” In particular, the suit claims, a nurse aide noticed a pressure ulcer on one of the residents, but his family and physician were not told about it. A nurse noticed the ulcer three days later but did not document the wound or inform the resident’s family or physician. According to the suit, the facility did not have the required nursing staff under state law to ensure that the resident received the care identified in his care plan.
In this case it is clear that the problem appears to have been a failure in the system to communicate the problem upward when it was first detected.
* A Connecticut SNF was fined $3,900 by the state Department of Public Health after a resident developed a severe pressure ulcer in 2017. The patient had been diagnosed with an unstageable deep tissue injury in the lower back and had been provided with a pressure-reducing cushion. However, records show that the cushion was underinflated on multiple occasions, and documentation from May through August failed to show that staff were monitoring its inflation.
* A Tennessee-based provider was fined more than $18 million in allowed claims to resolve a lawsuit brought by the United States and the State of Tennessee “for submitting false claims to Medicare and Medicaid for nursing home services that were grossly substandard or worthless,” and because its facilities had failed to “take prophylactic measures to prevent pressure ulcers, such as turning and repositioning patients.”
In addition to these and many other cases, there are multiple civil suits brought against SNFs by former residents or their families in terms of the Nursing Home Care Act. These seek damages in the hundreds of thousands of dollars for the development of “avoidable” pressure ulcers, some of which resulted in the deaths of residents.
To prove their case, the state (and private litigants) must show that a facility failed to evaluate the resident’s clinical condition and risk factors, failed to define and implement interventions consistent with resident needs, failed to monitor and evaluate the impact of the interventions, and failed to revise the approaches as appropriate.
Preventing these “avoidable” ulcers is therefore the critical element in avoiding legal trouble. To do this, all facilities should have a professional Standards of Practice guideline with which staff must be well acquainted.
All quality assurance team members should have a series of audits designed to ensure compliance with pressure injury prevention and care, and accurate documentation. These audit findings must have an upward chain of reporting to ensure that timely interventions are possible, and that prompt measures are taken.
Ensure that staff are aware of the legal compliance demands and that they realize their very careers and livelihood may depend upon rigorous enforcement of the rules.
