Pressure Ulcers: Improving Legal Defensibility through Documentation

​Presenting on Monday, October 28, 2013, at the annual conference of the American Society for Healthcare Risk Management in Austin, Texas, Roseann Brenner, J.D., managing partner, Goldfein and Joseph, gave “an overview of what I as a defense attorney would like to have at my disposal” in terms of documentation when defending against a pressure ulcer case in acute or long-term care. First, risk assessments should not involve simply coming up with a risk assessment score. Instead, “we have to look at their overall condition,” said Brenner. Staff should consider factors such as clinical conditions, nutritional indicators, skin moisture, general health, body temperature, and age. “It’s also clinical assessment, clinical judgment,” she said. Interventions should likewise be individualized. Generally, a policy should not state that all patients or residents should be turned and repositioned every two hours; rather, “we have to look at the person and take into account their clinical situation.”