Any nurses/medics around? Category 3 pressure sore: how common is it to develop one in hospital

[carerconundrums]

A dear elderly relative has been stuck in hospital for almost a month after a nasty fall. Discharge due for today after much planning and she is due to come to a care home near us.

We've been under pressure from the ward to find somewhere for her and have worked really hard to make it happen. Now just been told that she has a category 3 pressure sore and can't be discharged. It's so frustrating and she's really disappointed.

I don't understand how the sore has been allowed to develop this far? they put a boot on her foot on Friday but presumably it was already quite bad by then? Why wouldn't the sore have been treated before?

More generally, I feel the care has been really poor and she's been asking for help to get out of bed and move around so she doesn't lose mobility and it just doesn't happen.

Maybe I'm not being fair though so any advice / info from people who know about this area of health would be much appreciated.

Is she bebound, pressure sores are usually avoidable but there are occasions when they sadly develop, did she have it before she went into hospital, was she laying on the floor? She should have had a full mobility, skin, pressure sore , nutrrition, continence assessment and a full body map when she was admitted and her careplan should have this score, regularly updated and any sores documented, I think the staff have to report grade 3 and 4 sores. They should also have photos and any referall to the tissue viability nurse. Why do they say this has delayed her discharge? I would ask to speak to the ward manager, do you have power of attorney for health. Will the carehome keep her room open, has it been paid for?

Thanks for responding. She didn't have it when she went in and she was mobile at that point (not massively but walking around with wheeled walker before admission). She has been mostly bed bound since admission but has been sitting in a chair during the day.

I have LPA and have informed the care home. I have set up a direct debit for her. I haven't clarified whether she will be charged from today anyway but they have confirmed they will keep her spot at least

They are saying the TVN isn't available to review her today because she has 2-3 other patients to see but I've asked if she can be prioritised given she has been in hospital for so long and is due for discharge today. It's really hard to speak to anyone on the ward. They were going to call me back but haven't. I'm not local unfortunately, just trying to keep on top of things while WFH

Call PALS and they will visit the ward, Even if the tvn isn't available I'd expect the staff nurses to be competent in assessing, dressing and charting a pressure sore, that's basic good nursing practice. The carehome will need to order her a pressure mattress and will need the assessment from the ward, some carehomes report the ward if a patient arrives with a g3 or g4 sore. As her health poa you can ask to see or be given her assessments and with her permission be invited when they are updated.
The damage is done now but the paperwork needed is ..
Waterlow score, nutrition, continence , mobility, skin integrity, pressure sore risk. There should be updated assessments, the date the sore was noted and what action was taken, how often she is being turned for a change of position, photo, incident report, referral to tv. Is she going to a nursing or residential home, if its residential she will need a referall to the district nurses.

They do heal but it takes time, the foam boot will hopefully help, good luck. Poor lady.

You can call tvn yourself through switchboard and her social worker as this is now a delayed discharge

Both my in laws and parents were bed bound for months, being cared for variously at home and in an excellent nursing home. None of them developed pressure sores. For this reason I think they’re very avoidable. All four elderly people were immobile, but I saw great care ans great use of the right equipment. For this reason I really don’t think this should be happening g in a hospital setting.
your poor relative, OP x

you've all been so helpful. Thank you. Noting down all the advice.

If I can get agreement from the care home that she can be reviewed by the district nursing team at this end, I'm wondering if it's worth her shelling out for a taxi to get her here (she was due to be coming by hospital transport but suspect she will now have missed that for the day) just so she can get out of hospital asap. Do you think this is too risky?

Thank you - it does seem nuts that only one person in the hospital is able to review her wound.

The care home provides both residential and nursing support. She is going in as residential but may be upgraded to nursing on arrival.

I’d start by asking to speak to the ward manager/sister. explain what you have ready in place. Also ask re pressure ulcer whether it’s reported as hospital acquired and when was it spotted.

Care homes usually go in and assess before discharge so they should be able to confirm if they can meet her needs.

if you have no luck, speak to either the patient flow lead or clinical site manager. Their main job is to increase discharges from hospital so might be able to remove the blocks. Good luck!

I've just heard from the care home. The ward has contacted them directly so they are up to speed with everything and have explained what they need from the hospital in order to be able to admit her (it includes a full care plan from the TVN). Apparently the pressure sore (which is on her heel) was reported on Saturday but no explanation as to why it hasn't been reviewed until now.

In case the above wasn't clear - it was reported as a category 3 on Saturday. No idea when it was initially reported (presumably visible as a category 1 or 2 well before that) because it hasn't been mentioned to us at all

I worked in ICU, which I know has the advantage of 1:1 nursing, but also has patients who are at very high risk of pressure sores and they were very, very rare on our Unit. If anyone did get a significant pressure sore it would be investigated as an adverse incident.
I think you are right to ask questions about this. With appropriate equipment and presure area care most patients really shouldn't get pressure sores and it certainly shouldn't be seen as normal. In the early years of my career I would say that it was viewed as pretty much inevitable that long stay patients would get pressure sores, not infrequently really severe ones, but now, with better knowledge and the development of better equipment and products it's far less common.
Yes, nursing staff on some wards are extremely hard pressed and that is often at the root of these things but it doesn't make it acceptable. Complaining doesn't mean you are accusing anyone of deliberately causing harm, but if there are resource issues leading to patient harm then these need to be raised. There might not be a quick and easy solution - in fact there almost certainly won't be - but both staff and patients/families need to keep banging the drum if there is to be any hope of change.

@AgeingDoc thank you - appreciate your thoughts. The other thing is that the patient in question has absolutely no cognitive impairment, which I appreciate can make it harder to identify when something is causing pain or discomfort. She has actively been asking for help to get up and more around but this has only happened very rarely since admission. The whole thing feels very avoidable.

I have spent a lot of time on very busy wards with other elderly relatives and the care has on the whole been excellent. There is nowhere near the same level of pressure on his ward - so the whole thing feels very avoidable.

I'm sorry to hear that @carerconundrums though I am afraid to say I am not entirely surprised. I've been in hospital myself a few times in recent years and whilst some of the care I received was truly excellent, a lot was mediocre and some of it was very poor indeed. I chose to have my last surgery privately, which is honestly something I never, ever thought I would do, having spent my entire working life in the NHS. But my last stay on an NHS ward had been very disappointing, with basic stuff like fluid balance and pain assessments just not being done at all, medication not being given on time etc. Sometimes it could be put down to the ward being very busy but other times it really wasn't.
I have noticed that the prevailing view on here seems to be that it it is unreasonable to complain about the NHS because it's "free" and full of dedicated staff who are doing their best in very difficult circustances. If you complain then you're unreasonable, ungrateful or making things worse. I don't really buy that. Sure, if you are moaning about the quality of the coffee you are unreasonable but not if you're pointing out failures in care. In my experience there are indeed lots of dedicated and hard working staff who feel that they are unable to provide the highest standard of care due to staffing or resource shortages and they are happy for those issues to be raised. But equally there is nothing wrong with shining light on sub standard care delivered by poor staff because that does happen - not everyone is an overworked saint. If you have a concern, raise it.

Thank you - yes that has certainly been our experience this time around e.g. my relative is on Parkinson's medication, which needs to be administered on time. I just assumed she was being given it 4 x daily after admission but when I checked, they said they thought she'd been taking it herself by which time she'd missed a number of doses. So many other things weren't picked up until I or another visitor raised it.

I just spoke to the NIC and she couldn't explain why the pressure sore wasn't noticed before and said she thought maybe she hadn't been regularly checked.

Very few patients self medicate and I'd be very surprised if an elderly pd did, that would need to be assessed by the admitting nurse, doctor and pharmacist, there are protocols to follow and assessments to be done and recorded. Plus she'd need access to her meds which should be in a locked drawer if shes "off" she couldn't open the bottle anyway, it would be noted on her drug chart if she was self medicating so that's shite.,I think pd drugs are on the essential meds list too so should never be omitted without a given reason.

Exactly - that was my understanding. They just seemed to assume she'd kept them in her bag and was taking them at the right time but the poor woman had just had a massive bang to the head among other things.

That's really poor and should have been checked, were they signed for on her drugchart as self medicating, not that it matters, nothing ever gets done unless a complaint is submitted and the ward manager is told to investigate