The Expert: Johanna Ojeda, an expert on nursing care, testifies for the plaintiff, detailing requirements for nurses in such situations, explaining pressure sores, and concluding that the nursing staff failed to meet the standard of care in this situation.
Testifying as an expert for the plaintiff in a 2022 nursing home negligence case out of the 9th Judicial Circuit Court of Florida, Reed v. Life Care Centers of America, Inc., Johanna Ojeda, RN, a teaching nurse with over 30 years of clinical experience, addresses the causes, prevention, and treatment of pressure injuries of the skin.
The Omnibus Budget Reconciliation Act revised the federal standards for nursing home care and led to the establishment of the Office of Specialized Nursing Homes. In this clip, the testimony begins by referring to these standards as they apply to this case. The Quality of Care guidelines and regulations require when a resident enters a facility without skin breakdown, that the facility have measures in place to prevent this catastrophe from happening. Furthermore, the guidelines expect that if the skin does break down, that all necessary measures be taken to promote the healing of that wound. These guidelines apply to the defendant nursing home in this case.
Displaying these guidelines regarding skin integrity to the jury, Ojeda delves into their meaning. The nursing home is responsible to ensure that professional standards are maintained to prevent pressure ulcerations from occurring, “unless the patient’s clinical condition demonstrates that they were unavoidable.” If ulcers do occur, the regulations demand that proper precautions be taken to promote their healing, prevent their infection, and avoid further ulcerations.
The expert then expounds upon a Florida statute that outlines a nursing home resident’s rights. These include the right to adequate and appropriate healthcare and the right to be free from abuse and neglect. The Florida administrative code also has a section governing nursing homes, and this applies to this case as well.
The testimony then turns to educating the jury about pressure ulcers. A skin pressure injury is a “disruption of the skin caused by a lack of circulation due to unrelieved pressure.” The severity of these injuries is quantified as stages one through four. Stage One pressure injury implies that the skin is still intact, but it is reddened and does not blanch when compressed with a finger. Blood does not recirculate as it would with normally reddened skin. The damage here is confined to the top two layers of skin, the epidermis and the dermis. Stage Two would demonstrate an actual break in the skin with damage confined to those same top two layers. In Stage Three, the subcutaneous fat layer of the skin is exposed, damaged and ulcerated. Stage Four injury occurs when the ulceration goes beyond the previously mentioned three layers into muscle, fascia, and eventually exposing the underlying bone. This is the most severe pressure wound. In addition, there is a classification called “Unstageable Pressure Injury,” which is a wound that has scab formation at its top preventing accurate staging of the damage to the layers beneath it. This requires debridement, either physically or chemically, to be able to determine the depth of injury. When the patient arrived at the hospital from the nursing home in this case, her injury was unstageable. Once debrided, it was determined to be Stage Four.
Prior to admission to the nursing home, the plaintiff had been treated for a broken leg. Nursing expert Ojeda examined the patient records of the Florida hospital that provided this treatment, the records of the nursing home, the records of the hospital treating the plaintiff for the pressure ulcer, and the depositions of nurses and doctors involved in this care. Ojeda was of the opinion that the plaintiff was not provided with adequate and appropriate healthcare as demanded by these statutes and regulations. The care plan inadequately addressed the plaintiff’s high risk for skin breakdown, it was inappropriately administered, and it was not revised once the skin damage occurred. The nurses treating this patient failed to follow physician orders regarding the “skin tear” once it was discovered, and did not communicate with each other sufficiently to address this problem. Furthermore the caregivers failed to properly document the appearance of the wound other than calling it a “friction shearing wound” throughout the nursing home stay.
Nursing expert Ojeda’s testimony was central to the plaintiff’s case and proved to be effective as well. The jury awarded more than $12.3 million to the patient, including $10.625 million in pain and suffering damages. The defendant was found to be 87% at fault.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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