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Long-Term Care Survey Alert

Risk Management:

Before You Click That Wound's Picture, Consider This

Published on Thu Jan 17, 2008

Experts discuss pros, cons, alternatives to this documentation method.

A picture can be worth a thousand words. But its story could unfairly penalize, rather than support, your facility. That's why you have to proceed with caution when taking pictures of pressure ulcers that could end up in front of a jury or judge.

Former DON Marilyn Mines, RN, RAC-CT, BC, sees advantages to taking pictures of pressure ulcers at admission to prove the ulcers didn't develop in the facility. But she can also see the potential downsides. For example, the picture might show that a resident's ulcer deteriorated while he was in the facility, says Mines, manager of clinical services for FR&R Healthcare Consulting in Deerfield, Ill.

And that might not even be the facility's fault. "Deep tissue injury can start out as a small area that progresses to a huge pressure ulcer -- and that can be blown out of proportion by a plaintiff attorney," says Peggy Dotson, RN, a wound-care specialist in Yardley, Pa.

Beware the ugh factor: Attorney Joseph Bianculli notes that some of his nursing home clients do photograph at least some wounds. But some defense counsel always try to keep photos out as "inherently prejudicial" because "any reasonable juror would find the pictures disgusting," adds Bianculli, in private practice in Arlington, Va. Bianculli handled one case where an administrative law judge characterized a description of "mushy skin" as the most "disgusting thing [the person] had ever heard."

Get the Most From Pictures

Facilities that do take pictures of wounds should have policies and standard procedures specifying whether to photograph all wounds or just wounds of a certain severity, says Dotson. Also spell out whether to photograph wounds at admission, the frequency of picture taking, and who will take the pictures and how, she advises.

Ideally, the facility should use a sophisticated camera that has a built-in measurement grid that's superimposed on the picture, adds Dotson. But avoid using a digital camera, as digital pictures can be altered -- a point that an opposing attorney will likely point out.

Make sure the picture-taking protocol covers these bases, advises Dotson:

• Using the same camera each time;

• Taking the picture of the wound each time from the same distance and angle;

• Providing the same lighting or background to ensure a similar exposure for comparison;

• Including the date and patient's identification (name/ initials/ ID number) in the picture area each time to document the correct patient.

Tap this resource: The WOCN Society maintains that photography should serve "only to support the written wound documentation." The organization has a position statement that spells out suggested policies and procedures for taking pictures, including obtaining informed consent, validating the competency of picture-takers, storage of pictures, and other considerations. You can download the document at www.wocn.org/pdfs/WOCN_Library/Position_Statements/photoposition.pdf.

Solid Documentation a Safer Bet?

The best way to document pressure ulcers at admission is to reference the discharge record or hospital treatment records, believes nursing home defense attorney Chris Lucas, in Mechanicsburg, Pa. Many times, however, the hospital downstages a pressure ulcer by indicating it's a Stage 2 when it's really a Stage 3, he adds. But if the SNF staff documents a full body assessment at admission and notes the pertinent positive and negative findings, including the ulcer, the Departmental Appeals Board is going to accept that documentation "unless there's some reason to doubt its veracity."

In lieu of pictures, "provide narrative documentation in the record showing progressive attempts to heal a wound" where you evaluate the wound and change the care plan if it isn't getting better as expected, Lucas suggests.

Good documentation can provide a picture of what a wound looks like -- for example, "the measurements, peripheral tissue, odor, any tunneling, drainage, etc.," says legal nurse consultant Mardy Chizek, who finds this approach preferable to taking pictures of wounds.

Good advice: Assign one person or a team of a couple of staff to do the measurements in order to ensure consistency, advises Chizek, in Westmont, Ill. And if physical therapy is a "partner in wound care," make sure the PT staff and nursing wound documentation are consistent, she adds.

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