Man Dies From 8-inch wide, 5-inch deep bed sore (pressure sore, pressure ulcer, decubitus ulcer)

A nursing home resident died after his nursing home permitted an 8 inch bed sore (pressure sore, pressure ulcer, decubitus ulcer) to develop on his back.

He served in the Navy during the 1940's, then became a baptist minister. After his retirement, he was stricken with diabetes. In 2005, his wife realized she could not take care of her husband. "It grieved me beyond all measure to have to consider putting him in a nursing home," she said.

When she took him to a nursing home that a friend recommended he had no sores on his body," she said.

The nurses required her to make a list of the medical services her husband would need. She says she did so, paying close attention to a diabetic's diet. A few days later she realized something was not right when she had lunch with her husband, "They would give him apple juice, tropical drink, and all the things a diabetic should not have."

She also says her husband's feet were not elevated as doctors had ordered. "The bottoms of both heels were black, the flesh had died where they had not kept his heels floated," she described.

Thorn says her husband's condition continued to deteriorate. He was rushed to a hospital because of back pain. The doctor on duty determined he had a large bed sore. "Eight-and-a-half inches in diameter, five-and-half inches deep, it had gone to the bone."

After three days in the hospital, he died.

This story is one of many claims of improper patient care at this particular care facility. The U.S. Department of Justice identified 40 patients who were allegedly not getting the proper care there.

The DOJ report identified patients by initials because of privacy laws. The report states that Patient "L.M." died in May 2007. Days before his death, L.M. told staff members he had fallen twice. An investigation wasn't launched for five days.

On May 5, patient L.M. was found on the floor near his bed "unresponsive, pale, and clammy." He was rushed to a hospital, but died in the ambulance.

A DOJ consultant said that the bruising on his body appeared to be the result of slow internal bleeding, "He had fallen several times in the facility prior to the fall that caused his death." For more, read the story.

Pressure ulcer prevention in a nursing home and assisted living facility is critical. Specifically, nursing homes and assisted living facilities must prevent new pressure ulcers from developing, prevent existing pressure ulcers from getting worse, promote healing of those pressure ulcers, and prevent healed pressure ulcers from recurring. In a nursing home, the nursing home must ensure a patient who enters the facility without pressure ulcers does not develop them unless the patient’s clinical condition demonstrates the pressure ulcers were unavoidable. The nursing home must also ensure a patient with pressure ulcers receives necessary treatment and services to promote healing, prevent infection of an existing ulcer, and prevent new pressure ulcers from developing. In an assisted living facility, the facility must provide services to prevent clinically avoidable complications, including the development and deterioration of pressure ulcers.


Robert W. Carter, Jr. is a Virginia attorney whose law practice is dedicated to protecting the rights of the victims of nursing home and assisted living neglect and abuse in Richmond, Roanoke, Norfolk, Lynchburg, Danville, Charlottesville, and across Virginia.