Nursing Home Broken Leg Leads to Bed Sore and Death

Lugo v. NMS Healthcare of Springbrook

Nursing bed change This nursing home wrongful death claim was filed in Montgomery County after a woman broke her leg during a bed transfer, then developed a fatal bed sore while recovering from her injury. It was filed in Health Claims Arbitration on March 15, 2018, and it is the 129th medical malpractice case filed in Maryland this year.

Summary of Plaintiff's Allegations

An 84-year-old woman with impaired mobility needed assistance from a geriatric nursing assistant (GNA) when getting out of bed. While attempting to help the woman stand up, the GNA noticed that her right leg was caught in a sheet. The woman heard a popping sound and complained of pain. Long after the incident, x-rays confirmed that the woman suffered a femoral fracture.

The woman was transferred to Holy Cross Hospital, where she underwent surgery to repair her broken leg. During her recovery from her injury and surgery, the woman developed a sacral pressure sore. The pressure ulcer became infected, leading to sepsis and her eventual death.

Additional Comments
  • According to the nursing home charts, the incident that caused the woman's broken leg occurred around noon. Even though the woman was "crying because of pain," she was not brought to the hospital for an evaluation until the following day.

  • It is unclear whether the woman developed the bed sore while she was at Holy Cross Hospital or at her nursing home. Based on the language in the statement of claim, it seems as though the plaintiffs are arguing that the broken leg incited a string of events that ultimately led to the woman's death. They claim the broken leg led to the pressure sore, which became infected and led to the woman's death, but they are not claiming that the bed sore developed due to negligent care. Speculatively, this line of reasoning makes it seem as though the woman was at Holy Cross Hospital when she developed the pressure ulcer.

  • Bedsores, or decubitus ulcers, are a known risk to patients whose injuries limit their mobility. This woman was clearly an at-risk resident. What happened is that pressure built up on her sacrum creating a bedsore. Bedsores increase the risk of sepsis, which can lead to death.

  • The standard of care required NMS Healthcare to identify this woman as a patient with a risk of bedsores. This requires the nursing home to monitor her skin carefully, use a dynamic or static mattress and additional padding, and move the patient every two hours to avoid the development of bedsores. The nursing home should also keep the skin moist and make sure the patient is getting plenty of food and water.

  • Once a wound is identified, the standard of care requires efforts to keep the area dry. dressing changes as needed to ensure that the dressing remains dry and get a doctor involved for treatment.

  • NMS has had a history of trouble. This particular nursing home has not done well.

  • Montgomery County.
  • NMS Healthcare of Springbrook, LLC
Hospitals Where Patient was Treated
  • Holy Cross Hospital
  • Failing to properly prepare the woman for a bed transfer by clearing her legs of any obstructions before attempting the transfer.

  • Failing to secure the scene, inspect the room for potential hazards, and take appropriate action to minimize risk of harm to a patient with limited mobility.

  • Failing to immediately report the incident and provide emergent medical care.

Specific Counts Pled Plaintiff's Experts and Areas of Specialty
  • Mary C. Crossland, R.N., CWCN
  • Marc S. Itskowitz, M.D., FACP, internal medicine
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