No Bull, Just Results

Attorney Sanga Turnbull

Do You Know Why Medicare Considers Bedsores Avoidable?

On Behalf of | Feb 7, 2020 | General

In 2007 Medicare reported more than 250,000 cases of preventable bedsores.  To put that in real world context, 7 percent of acute care patients will develop a bedsore according to the International Expert Wound Care Advisory Panel.  Medicare estimates that 8.9% of NURSING HOME residents will develop one.  The National Pressure Ulcer Advisory Panel is widely considered the leading organization on bedsore research and clinical treatment guidelines.  They estimate that as many as 24% of Nursing Home residents will develop bedsores.

In 2008 Medicare had enough!  Medicare’s policy shift was simple, they would no longer pay health care institutions for poor quality care.  They identified the most common, avoidable complications in these settings, and surprise, bedsores ranked in the top eight.  This list is now widely known as Medicare’s “Never Events.”  Hospitals were specifically signaled out and since 2008 Medicare will NOT PAY for any bedsores that the patient develops while in the hospital.

Not to be left out, Medicare revised it’s criteria for Nursing Homes as well.  Medicare regulations state very simply that a facility must ensure:

A resident that enters a facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates they were unavoidable?

That begs the question what does Medicare consider avoidable?  Under the regulations if a nursing home fails to do one or more of several criteria the pressure sore is considered avoidable.  In other words, if your family member is admitted to a nursing home without a bedsore, and they later develop one, the nursing home is legally responsible for your loved one’s pain and suffering if it’s found the nursing home failed to do one or more from the list below:

  • Evaluate a resident’s clinical condition and pressure ulcer risk factors such as immobility, incontinence, or impaired nutrition;
  • Implement preventative or ongoing treatments to prevent the development and worsening of the bedsore such as turning and repositioning every hour or two, using skin barrier cream, or using pressure reduction surfaces for beds and wheelchairs;
  • Monitor the effectiveness of the treatment plan; and
  • Revise the treatment as needed.
  • With the Federal government applying increasing pressure on hospitals and nursing homes to prevent bedsores have these institutions and the care they provide improved?  Or have they resorted to other ways to avoid suffering financial penalties which still neglecting patient and resident care?

    The Federal government was curious about that exact question.  What they found should cause alarm in all concerned family members and patient advocates. In order to track whether in house developed bedsores were decreasing Medicare compared past and present billing codes.  When a hospital or nursing home wants to get paid for treating a bedsore, they enter a billing code indicating the location on the body and the stage, or how bad.  In order to be counted as developing inside a facility, the hospital or nursing home is required to enter both a site and the stage when submitting its billing codes.  The birth of a loophole.  It seems like a reasonable approach until you learn that Medicare only looks at the first eight billing codes.  When Medicare began looking at billing codes they noticed an increasing and disturbing trend.  While the site of the bedsore was in the first eight codes, the location was number nine or lower.  In short since both codes weren’t in the top eight hospitals continued to be paid even though the level of patient care had not improved.

    As a concerned family member or advocate you should know that the staff is aware of the “Never Events” policy.  Therefore, to ensure they aren’t blamed for the hospital not being paid they have every incentive to conceal and hide the development of a bedsore from you.  Now more than ever it is important for family members and advocates to remain persistent and loud in ensuring their loved ones are being assessed and treated to prevent the development of bedsores.  The steps to needed to prevent these devastating injuries are simple.  Far too often unfortunately, whether due to understaffing or simple neglect, the simple isn’t followed and these Never Events caused serious injuries and in some instances death.