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Lack of Prevention Leads to Serious Complications

A patient with intellectual challenges developed toxicity due to a buildup of phenobarbital she was taking to combat seizures. Following an adjustment in her anti-seizure medications, she was transferred to a rehabilitation facility.

For 17 days, the patient’s medical charts indicated that her skin was dry and intact. On the 17th day, the patient was noted for the first time to have an unstageable pressure ulcer with tunneling, foul odor and purulent drainage. This note of the advanced pressure wound came within one hour of a previous note stating the patient’s skin was dry and intact.

The patient was hospitalized and underwent a surgery to remove damaged tissue from the stage IV pressure ulcer. The patient then received antibiotic therapy and required a more extensive stay in rehabilitation.

A review by wound care nurses revealed that the rehabilitation center had an incomplete plan of care to prevent the development of a pressure ulcer. Not surprisingly, the nurses found that the staff of the rehabilitation unit did not recognize a developing pressure ulcer, thus care was not initiated before it reached stage IV and required surgery.

With this information in hand, Hyatt & Weber was able to secure a settlement of $535,000 to compensate the patient.