Risk factors for infections among the elderly are a focus of many long-term care (LTC) facility medical malpractice lawsuits. Infections in long-term care facilities are associated with higher rates of morbidity, mortality, rehospitalization, extended hospital stays, and substantial expense. Urinary tract infections (UTIs) are among the most common infections seen in LTC facilities. For these reasons, many medical malpractice lawsuits involve patients who were treated for an infection of some kind.

Best Practices for Preventing Infections are the Best Defense

Best practices that facilities should observe to prevent and treat infections are its best defense. The difficulty in defending medical malpractice cases involving infections is typically a general inability to determine whether those best practices were used. One of the most important best practices is also one of the most difficult to track: whether the nursing staff practiced proper hand hygiene.

Other Practices: Education, Surveillance, Evidence-Based

Other practices recommended by The Joint Commission in their January 1, 2018 Patient Safety Goal 7 are to educate staff about multidrug-resistant organisms and prevention strategies upon hire, and periodically thereafter on a schedule determined by the organization. They recommend implementation of a surveillance program for multidrug-resistant organisms to measure and monitor prevention processes and outcomes, including infection rates, compliance with guidelines and evaluation of the education programs provided to staff. The Joint Commission also recommends evidence-based practices to prevent central line-associated bloodstream infections.

Maintaining Proper Control of Environment

Additional best practices include maintaining proper control of the environment, especially in the event of infectious outbreaks. This may include isolation, or teaching families about using and properly disposing of masks and gloves when visiting a patient with an infection. Prevention is also important, and is typically addressed in care plans.

11 Risk Factors for Infections Among the Elderly

A common approach among defense attorneys to assess infection-related medical malpractice cases is to determine whether the nursing staff were aware of the common risk factors for infection, then determine whether they wrote an appropriate care plan that addressed those risk factors. The defense will then assess whether staff recognized signs and symptoms of infections, notified the physician in a timely manner, and provided for proper treatment as ordered.

The following risk factors for infections are commonly associated with infections in LTC settings:

• Diminished immune response
• Advanced age
• Malnutrition
• The presence of multiple chronic diseases, a status that is often accompanied by many different medications
• Cognitive deficits that may complicate compliance with basic sanitary practices, such as hand washing
• Diminished ability to complain of or self-identify symptoms, or increased likelihood of presenting with atypical symptoms or signs of infection
• Functional impairments such as incontinence or immobility
• Blunted febrile response to infection
• Use of invasive devices like catheters, ventilators, or feeding tubes
• Growing population of post-acute residents recovering from a hospitalization
• Institutional factors like turnover, payment, rates of transfer, and intensity of services

Using the Medical Record to Assess the Care Provider’s Diagnosis and Treatment

One strategy for medical record review is for the defense attorney—or someone working on the defense’s behalf—to compare a patient’s care plan with his or her treatment records. For example, if a patient entered the nursing home with a urinary catheter, the defense should check the medical record to determine whether the nurse obtained orders for catheter care and examine the treatment records for indications of care performance. Was the catheter changed regularly? Did the care plan include instructions for gravity drainage for the catheter bag to avoid reflux? In short, make sure the care plan was accompanied by best practices for prevention and treatment.

Consider the Care Setting

Another consideration is the care setting in which the patient may have contracted the infection. For example, patients who are diagnosed with a Clostridium difficile colitis (C. diff) infection are commonly infected in a hospital setting, but remain asymptomatic for a few days—perhaps until they’re recovering in a nursing home. In C. diff cases, the defense should review the medical record to see what treatment the patient was receiving in his or her prior setting, as the infection is generally caused by a heavy antibiotic regimen that disrupts the natural flora in the stomach.

Consider Differences Between Hospitals and Long-Term Care Facilities

Lastly, the defense is wise to consider the differences between hospitals and long-term care facilities, as the care models can differ a great deal. Nursing homes may be less equipped to recognize and diagnose infections due to their staffing models and more limited access to diagnostic equipment. Additionally, LTC facilities’ residential nature includes providing socialization and group activities, in contrast to self-contained care in hospitals.

The Difference Between Winning and Losing: The Medical Record

Because it can be challenging to determine—and prove—that nursing staff followed best practices, it is crucial that defense attorneys are familiar with the risk factors for infection. Knowing how to review both care plans and the treatment history within the medical record can be the difference between winning and losing in court. For more information about how to get assistance in this process, click here.