2022Jane Doe, age 78, was a resident at an assisted living facility (ALF), when she was admitted to Woe Hospital for pneumonia. The plan of care for her was to return to the ALF after a short admission. During the first 3 days of admission to Woe she lost her ability to communicate, was in a very weakened state, and could not turn and reposition herself in her bed or get out of bed. On the morning of the third day of admission, the morning nurse did her assessment and found her in bed with stage II pressure wounds on her buttocks. The nurse requested a wound care consultation but this did not take place for 6 days. The nursing staff failed to turn and reposition her every 2 hours even though she remained weak and at “max assist” with no bed mobility and no ability to reposition herself without assistance from the staff. Her pressure wounds deteriorated and when discharged from Woe, 15 days after admission, her ALF assessed her and found her wounds made it impossible for her to return to the ALF. She had to be admitted to a skilled nursing facility for extensive rehabilitation and wound care for 5 months. Doe underwent multiple surgical wound debridements for her pressure wounds. Her wounds stabilized but never completely healed. Her condition remained weakened and she was never able to walk again and could only sit in a wheelchair a few hours a day because of her wounds. Plaintiff’s expert opined that the pressure wounds were a significant cause of death.