Falls and Pressure Ulcers: "Never Events" In Hospitals and Long-Term Care Facilities

They call them “Never Events” – events that can be prevented or avoided, such as a pressure ulcer (PU) or a fall. Simply, the hospital or Long Term Care (LTC) facility, by and through its staff, must have a game plan (known as a “Plan of care”) to prevent such occurrences. No two patients are the same. They differ in age, body shape, underlying medical conditions and many other ways. Each person’s unique characteristics make him susceptible to injuries, such as falls or pressure ulcers.

As a result, every hospital or LTC facility must recognize that every patient who comes through its doors deserves to be treated as a unique individual.   Each and every hospital or LTC facility must understand and appreciate that all patients should be protected from sustaining insult or injury at the facility even if they are infirm or elderly. Injuries to the infirm or elderly, which have been recognized as “serious adverse events,” are otherwise preventable if the facility, by and through its staff, creates and implements policies and procedures that prevent these events.

The first key to prevent a “serious adverse event” is “prevention.”  By analogy, when you leave your home, you turn off your oven.  Why:  to prevent or reduce the risk that a fire can start.  When you leave your home, you lock your doors.  Why:  to prevent or reduce the likelihood that you will be robbed.  These same principles of “prevention” apply to a healthcare setting in order to reduce or prevent the likelihood that a patient or resident will fall or develop of a pressure ulcer.  If a patient is weak, medicated or confused, the facility by and through its staff, must perform an assessment of that individual’s fall risk and then based upon that assessment implement a game plan specific to that individual’s unique characteristics and needs that will help reduce or prevent the patient from falling.  Hospital and LTC facilities cannot play the proverbial “Monday morning quarterback” and proclaim that they “should’ve done xyz.”  A plan must be in place and each medical provider must be on the same page to protect and prevent injury and harm to patients/residents.

It is no different with pressure ulcers. Pressure ulcers, like falls, are unnecessary and preventable events. While patients and residents are admitted to a hospital or LTC for a variety of reasons most commonly, they are admitted because these patients have medical problems and are incapable of fully caring for themselves. Patients admitted to a hospital or to an LTC are not always aged. Patients/residents can be admitted for a simple low back procedure but because they may have lower extremity weakness they cannot elevate their feet/heels off of the bed. What the facility, by and through its staff, must recognize is that these individuals must be evaluated for their risk of pressure ulcers because they cannot fully move their extremities. Pressure ulcers are known to occur in this population and as such, the nursing staff in these facilities should have heightened awareness of pressure ulcers occurring in this setting. The nursing staff should be trained to recognize any bony prominence as a risk for a pressure ulcer to occur.

It is often believed that the low back/buttocks is generally the spot in which pressure ulcers develop. However, they also often develop on the heels, back of the head, elbows and thighs. As such, nurses should be trained to look for many other bony prominences in varying locations of the body so that they can assess them and then implement a plan of care to prevent them from occurring.

So when you see a loved one admitted to a hospital or LTC facility you need ask the following important question:  (1) Does this facility have a game plan for my loved one to prevent serious adverse events which should be foreseeable and which can be prevented with the proper care and treatment? Certainly, there are no guarantees and a hospital or LTC staff, even implementing the best medical or long term care, cannot possible prevent every event from occurring. However, if the facility (hospital or LTC) doesn’t have a plan of care that is specific to your loved ones unique needs and/or therefore, fails to implement a plan of care if necessary, that facility is responsible every time for failing to protect your loved one from harm.

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