Homicide by Decubitus Ulcers in Nursing Home Patient

In a case with major implications for U.S. nursing homes, the State of Hawaii recently convicted a nursing home operator of manslaughter after an elderly resident died of a massive infection caused by pressure sores.

"With the introduction of criminal prosecution for gross neglect, a new weapon against poor nursing care has appeared," write Dr. Vincent J.M. Di Maio and Theresa G. Di Maio in Volume 23, Issue 1 of The American Journal of Forensic Medicine and Pathology. Dr. Di Maio is Chief Medical Examiner of Bexar County, Texas, and Editor-in-Chief of the Journal.

Pressure sores--also called decubitus ulcers or "bed sores"--are caused by remaining in one position for a prolonged period of time. Although pressure sores are common in elderly nursing home residents--particularly those with impaired consciousness or immobility--they are preventable with proper nursing care.

The Hawaii case involved a 79-year-old woman receiving care in an "adult residential care home," a type of nursing home providing basic care for small numbers of residents. At a visit made for another reason, the woman's doctor noticed she had pressure sores on her lower back and buttocks. When the sores did not heal, the patient was referred for surgical treatment. The nursing home operator was provided with clear instructions on caring for the ulcers and told to bring the patient back in one week.

However, the follow-up appointment was not kept. A few weeks later, the patient was brought to the hospital in cardiac arrest. At that time, the pressure ulcers on her lower back had gotten much worse and she had developed new sores on her legs.

The patient died of septic shock, and an autopsy showed that this infection resulted directly from the pressure sores. The State charged the nursing home operator with negligence for allowing the ulcers to progress to such a severe state while failing to seek medical care. The result was a conviction for manslaughter.

In the past, pressure sores have been regarded as a normal occurrence in nursing home patients, despite the fact that they are preventable with routine nursing care--eg, turning and repositioning the patient every few hours. In recent years, some state and local governments have identified cases of pressure sores leading to death so grievous as to warrant criminal prosecution.

"Many nursing home facilities in this country follow managerial policies that result in the neglect and death of elderly patients," the authors write. They cite understaffing and lack of appropriate supervision by registered nurses as the major dangers to residents' health.

In the past, civil lawsuits and regulatory fines were the main consequences for nursing homes that abused or neglected elderly residents. More recently, government agencies have become "much more aggressive" in citing health care institutions for allowing patients to develop pressure sores. As nurse staffing levels continue to decline, the risk of criminal prosecution for gross patient neglect may eventually extend from nursing homes to hospitals and hospital personnel, the authors believe.

The American Journal of Forensic Medicine and Pathology is the Official Journal of the National Association of Medical Examiners. Drawing on the expertise of leading forensic pathologists, lawyers, and criminologists, the Journal presents up-to-date coverage of forensic medical practices worldwide.