• 11: Office
• 12: Home
• 13: Assisted Living Facility
• 14: Group Home
• 31: Skilled Nursing Facility
• 32: Nursing Facility
• 33: Custodial Care Facility

• Problems with patient-physician communication
• Poor relationship with the healthcare provider
• Desire for information about what happened
• Feeling of not being informed
• Desire to prevent the situation from happening to another person
• Unmet expectations or unwanted outcomes
• Desire for accountability/revenge
• Suspicion of cover-up
• Feeling of not being appropriately referred
• Financial need
• Pain and suffering
• Advice from another (knowledgeable friend or acquaintance or healthcare provider)
• Television ad for law firm

Sheldon vs United States

• A patient sued the hospital for not providing wound care instructions after receiving treatment for a bite in the emergency room.
• The wound became gangrenous, which resulted in finger amputation.
• The patient argued that the lack of wound care instructions led to the gangrene and amputation.

Gonzalez vs Padilla

• A patient suffered a degloving wound injury.
• The patient was stabilized in a hospital and then transferred to a rehabilitation facility to receive hyperbaric oxygen therapy (HBOT) for 4 weeks.
• The patient did not tolerate HBOT well and only received 3 treatments.
• The patient was discharged home with home health services.
• Neither the hospital nor the rehabilitation facility ordered antibiotics.
• Nine days after discharge, the home health nurse discovered gangrene in the wound.
• This resulted in an amputation.

McComas vs Miller

• A patient's foot ulcer was treated for over a year with regular weekly visits, including a skin graft and resection.
• The patient was compliant with all care.
• The wound was never biopsied and turned out to be a malignant melanoma.
• The patient died of metastatic disease.
• The patient's family sued for failure to diagnose the correct wound type, resulting in delayed intervention and death.

Bartlett vs Cope

• A patient was treated weekly from February to June for "foot cellulitis".
• The wound deteriorated and was diagnosed with osteomyelitis.
• A partial foot amputation was performed in June.
• The healthcare provider was sued for failing to use expected wound evaluation practices to evaluate the lack of healing progress for a non-healing foot ulcer and failing to diagnose and treat the osteomyelitis until amputation was required

Wound description

• Inconsistent wound location: documentation alternates between coccyx and sacrum or between sacrum and ischium.
• Laterality errors: right versus left side is recorded incorrectly.
• Incorrect use of medical terminology when describing the wound bed tissue, exudate, and the periwound skin.
• • For instance, if a wound bed is documented as 50% erythema and 50% yellow slough, the clinician is using incorrect terminology. Erythema is a term used to describe the periwound and not the wound bed, which would be described as covered with granulation tissue, slough, or eschar. For details on terminology, see topic "How to Assess a Patient with Chronic Wounds".
• Inconsistent documentation: A new tunnel or drainage is documented and measured by the nurse, yet the provider notes “no change in wound status”. 
• Missing wound identifiers: wound numbers (e.g., “Wound 1,” “Wound 2”) are not used consistently in progress notes.

Wound measurements

• Omitted or partial documentation: the standard wound measurement should include length, width, and depth of the wound, and measurement of tunnels and/or undermining if present.
• • If a previously documented tunnel, for example, a 3 cm tunnel documented one week prior and packed, is not documented during the current visit, it could indicate that the packing was not completely removed or that an assessment was omitted.
• Inconsistent documentation: 
• • If the nurse and provider record different wound measurements during the same visit, inconsistent documentation can undermine the reliability of the documentation in legal proceedings.
  • Wound measurements demonstrate increased size since last visit, but the provider states that the wound “is smaller” or “improving.”
• Contradictory documentation: documentation of wound depth when a wound is also documented as “healed”, “resolved”, or “epithelialized”. These terms mean the wound is closed completely and therefore does not have depth.

Wound photography

• Common legal risks related to wound photography 
• Blurred images: poor focus can obscure important wound characteristics (depth, undermining, tunneling), undermining clinical decision-support and legal defensibility.
• Inconsistent distance and orientation: varying camera-to-wound distance or angle between visits makes it impossible to compare healing progress objectively.
• Omitted images: failure to capture photographs at every visit—or missing key views—creates gaps in the medical record.
• Mislabeling:  Applying the wrong wound number, side (right vs. left), or patient identifier can lead to treatment errors and undermine chart integrity.
• Non–HIPAA–compliant images: Including patient identifiers in photos or storing them insecurely violates HIPAA and exposes the facility to privacy breaches.

Vascular assessment for lower extremity ulcers

• Lack of documentation of vascular assessment for lower extremity ulcers, including:
• • Full vascular examination (e.g. pulse palpation, capillary refill, skin temperature).
  • Ankle–Brachial Index (ABI) and/or Toe–Brachial Index (TBI) or other form of noninvasive arterial vascular testing.
  • See section 'Noninvasive Arterial Tests' in topic "Arterial Ulcers - Introduction and Assessment"

Ulcer Classification/ Staging 

• Inappropriate utilization of ulcer classification/staging systems: the Wagner Grade Classification is specifically for diabetic foot ulcers and the National Pressure Injury Advisory Panel (NPIAP) Pressure Ulcer/Injury (PU/PI) Staging system is specifically for PU/PI . Documenting a venous stasis ulcer with a Wagner Grade, such as Grade 1, or classifying an abdominal surgical wound as a Stage 3 is inaccurate documentation.
• PU/PI incorrect staging: a PU/PI is incorrectly staged when documentation indicates a 100% eschar-covered wound bed and also specifies a depth level. In such instances, the depth cannot be determined, and therefore the stage should be classified as unstageable.
• • See topics 

Diagnosis

• Misdiagnosis of PU/PI: 
• • Coding and naming an ulcer as a PU/PI when no pressure, friction, or shear is present.
  • Mis-identifying moisture associated skin damage and Stage 2 PI/PU
• Coding misalignment: the International Classification of Diseases, Tenth Revision (ICD-10) code assigned does not match the clinical documentation.

Treatment

• Inconsistent provider order and actual treatment: discrepancy between the provider order and actual treatment can happen when orders are verbalized and carried out and documented at a later time with omissions or differences. For instance:
• • During a nurse visit, the nurse proactively changes the dressing type to meet the changing characteristics of a wound, however fails to contact the treatment provider and obtain an order for the change in treatment.
  • It is important to note that: 
  • • All dressings require a provider order.
    • Nurse Visits and Home Care visits each require a provider order, frequency, and reason. They are part of the documented plan of care.

Patient education

• Lack of documentation that patient education was provided. Documentation should include wound care instructions (e.g. written, verbal, handouts) including but not limited to: 
• • Procedures performed
  • Dressings applied
  • Nutrition guidance
  • Potential signs and symptoms of complications, how to recognize them, when to contact the healthcare provider, and who to contact. 

Electronic Health Record (EHR)

• EHRs are used in most healthcare settings and may offer faster documentation through templates and checkbox answer selections.
• Common legal risks associated with the use of EHRs: 
• • Copy and paste: clinicians should be careful not to copy and paste the same note or assessment from visit to visit. Each encounter should contain information from the current assessment which is rarely 100% the same as the previous visit.
  • Checking boxes inadvertently: healthcare workers need to be aware of the verbiage generated when they check a box in the EHR. Checking “WNL” for pedal pulses may generate verbiage for both right and left feet on a patient with a AKA.
  • Delayed documentation: ensure documentation is timely. The EHR tracks the exact time of all documentation. Avoid large gaps in time between when care is performed and documentation of that care.

Advanced Practice Registered Nurse (APRN)

Role: The APRN works independently or in collaboration with a physician (according to state practice acts and facility/agency policies) to lead the interdisciplinary wound care team to plan and provide care for the patient at risk of or with wound care needs. Responsibilities include but are not limited to:

• Abides by state practice acts, regulations, and laws established within the state/states of licensure, and facility or agency-based credentialing and privileging requirements to prescribe medications, order tests and treatments, and make necessary referrals.
• Independently or in collaboration with the physician comprehensively assesses and establishes wound diagnosis, prognosis, and wound care treatment.
• As a leader, provides oversight, assistance and guidance to other members of the interdisciplinary wound care team to establish and provide a comprehensive approach to wound management that includes all disciplines and promotes optimum outcomes.
• Provides bedside treatments to include conservative sharp debridement, when indicated and permitted by state practice acts and facility policy.
• Independently, or in collaboration with other interdisciplinary wound care team members, develops and implements wound prevention, skin management, and wound treatment programs and provides corresponding education to patients, family members/caregivers, and facility/agency staff.
• Collaborates with other wound care professionals to promote research and assess findings to establish updated, relevant approaches to improve wound prevention and wound care practices.
• Collaborates with other wound care team members to promote the facility or agency quality improvement program.

Registered Nurse (RN)

Role: The RN plays a key role in oversight of the patient at-risk of or with wound care needs. Responsibilities include but are not limited to:

• Abides by state practice acts, regulations, and laws established within the state/states of licensure.
• Develops and implements wound prevention, skin management, and wound treatment programs and provides corresponding education to patients, family members/caregivers, and facility/agency staff.
• In conjunction with prescribing providers orders (physician, APRN, physician assistant), provides consultation and/or hands-on care for wound prevention or management. Performs comprehensive assessments and reassessments to determine the most appropriate and cost-effective use of wound management products and resources. Hands-on care may include conservative sharp debridement/chemical cauterization with a provider order, per facility guidelines and if allowed according to individual state practice act.
• Delegates appropriate wound prevention and wound care actions to LPN/LVNs and unlicensed assistive personnel (e.g. health technicians, nursing assistants).
• As an interdisciplinary wound care team member, collaborates to establish individualized, comprehensive care plans that promote wound prevention and healing.
• Establishes, reevaluates and revises facility policies, procedures, and guidelines governing wound care, based on needs, evidenced-based trends, and industry changes.
• Observes patient’s response and wound status, reporting any changes to the provider or supervising clinician, according to facility or agency guidelines.
• Provides and reinforces education to patients, family members/caregivers, and facility/agency staff regarding preventative measures, interventions, and individualized patient treatment plans.
• As a patient advocate, promotes facility/agency-based quality improvement that addresses wound prevention and the specialized complex needs of the wound care patient.

Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN)

Role: Under the supervision, delegation, and guidance of the registered nurse or prescribing provider (e.g. physician, APRN, or physician’s assistant), the LPN/LVN provides the prescribed care to the patient at-risk of or with wound care needs. Responsibilities include but are not limited to:

• Abides by state practice acts, regulations, and laws established within the state/states of licensure.
• As an interdisciplinary wound care team member, provides input for care plan consideration that promotes wound prevention and healing.
• Implements preventative care, monitors skin status, and performs wound treatments per orders in the individualized patient’s treatment plan.
• Provides and reinforces education to patients, family members/caregivers, and facility/agency staff that is consistent with the established care plan for preventative measures, interventions, and individualized patient treatments.
• Observes patient’s response and wound status, reporting any changes to the registered nurse or supervising clinician, according to facility or agency guidelines.
• Contributes to the facility or agency quality improvement program, as assigned.

Physical Therapist (PT)/Occupational Therapist (OT)

Role: The PT and OT play a key role in oversight of the patient at-risk of or with wound care needs while working under the guidance of a prescribing provider (e.g. physician, APRN, Physician Assistant). Responsibilities include but are not limited to:

• Abides by state practice acts, regulations, and laws established within the state/states of licensure.
• As part of the interdisciplinary wound care team, contributes to the establishment and revision of the individualized, comprehensive care plan to promote wound prevention and healing, and provides input for care plan consideration and implementation per established protocols.
• In conjunction with prescribing providers orders (physician, APRN, physician assistant), provides consultation and/or hands-on care for wound prevention or management.
• Delegates appropriate actions for adjunctive modalities specific to therapy administration, as part of an established individualized plan of care, to PT assistants and OT assistants.
• Assesses, recommends, and provides adjunctive modalities specific to therapy administration within the state’s scope of practice for therapy clinicians.
• Assesses and makes recommendations for support surface selection.
• Provides and reinforces education, consistent with therapy-related aspects of the individualized care plan (e.g. proper positioning, mobility), to patients, family members/caregivers, and facility/agency staff.
• Observes patient’s response and wound status, reporting any changes to the supervising clinician, according to facility or agency guidelines.
• Contributes to the facility or agency quality improvement program, as assigned.

Physical Therapy Assistant (PTA)

Role: The PTA plays a key role in oversight of the patient at-risk of or with wound care needs while working under the supervision of a Physical Therapist (PT). Responsibilities include but are not limited to:

• Abides by state practice acts, regulations, and laws established within the state/states of licensure.
• As part of the interdisciplinary wound care team, contributes to the establishment and revision of the individualized, comprehensive care plan to promote wound prevention and healing, and provides input for care plan consideration and implementation per established protocols.
• In conjunction with prescribing provider’s orders (physician, APRN, physician assistant), and supervision of the PT, provides consultation and/or hands-on care for wound prevention or management.
• Initiates appropriate actions for adjunctive modalities specific to therapy administration, as part of an established individualized plan of care, and as directed by the PT.
• Assesses, recommends, and provides adjunctive modalities specific to therapy administration within the state’s scope of practice for PTAs.
• Assesses and makes recommendations for support surface selection.
• Provides and reinforces education, consistent with therapy-related aspects of the individualized care plan (e.g. proper positioning, mobility), to patients, family members/caregivers, and facility/agency staff.
• Observes patient’s response and wound status, reporting any changes to the supervising clinician, according to facility or agency guidelines.
• Contributes to the facility or agency quality improvement program, as assigned.

Occupational Therapy Assistant (OTA)

Role: The OTA plays a key role in oversight of the patient at-risk of or with wound care needs while working under the supervision of an Occupational Therapist (OT). Responsibilities include but are not limited to:

• Abides by state practice acts, regulations, and laws established within the state/states of licensure.
• As part of the interdisciplinary wound care team, contributes to the establishment and revision of the individualized, comprehensive care plan to promote wound prevention and healing, and provides input for care plan consideration and implementation per established protocols.
• In conjunction with prescribing provider’s orders (physician, APRN, physician assistant), and supervision of the OT, provides consultation and/or hands-on care for wound prevention or management.
• Initiates appropriate actions for adjunctive modalities specific to therapy administration, as part of an established individualized plan of care, and as directed by the OT.
• Assesses, recommends, and provides adjunctive modalities specific to therapy administration within the state’s scope of practice for OTAs.
• Assesses and makes recommendations for support surface selection.
• Provides and reinforces education, consistent with therapy-related aspects of the individualized care plan (e.g. proper positioning, mobility), to patients, family members/caregivers, and facility/agency staff.
• Observes patient’s response and wound status, reporting any changes to the supervising clinician, according to facility or agency guidelines.
• Contributes to the facility or agency quality improvement program, as assigned.

Physician

Role: The physician works independently or in collaboration with an APRN/PA to lead the interdisciplinary wound care team to plan and provide care for the patient at-risk of or with wound care needs. Responsibilities include but are not limited to:

• Abides by state practice acts, regulations, and laws established within the state/states of licensure, and facility or agency-based credentialing and privileging requirements to provide patient care.
• Independently or in collaboration with the APRN or PA, the physician establishes wound diagnosis, prognosis, and wound care treatment.
• Orders appropriate referrals and tests, when indicated.
• As a leader, provides oversight, assistance and guidance to other members of the interdisciplinary wound care team to establish a comprehensive approach to wound management that includes all disciplines and promotes optimal outcomes.
• Collaborates with the APRN, PA, RN and other wound care team members to develop a wound prevention plan.
• Provides bedside treatments to include conservative sharp debridement when needed.
• Works with the interdisciplinary team to educate patients, family members/caregivers, and facility/agency staff regarding preventative measures, interventions, and individualized patient treatment plans.
• Collaborates with other wound care professionals to promote research and assess findings to establish updated, relevant approaches to improve wound prevention and wound care practices.
• Collaborates with other wound care team members to promote the facility or agency quality improvement program.

Physician Assistant (PA)

Role: The PA works independently or in collaboration with a physician (according to state practice acts and facility/agency policies) to lead the interdisciplinary wound care team to plan and provide care for the patient at risk of or with wound care needs. Responsibilities include but are not limited to:

• Abides by state practice acts, regulations, and laws established within the state/states of licensure, and facility or agency-based credentialing and privileging requirements to prescribe medications, order tests and treatments, and make necessary referrals.
• Independently or in collaboration with the physician comprehensively assesses and establishes wound diagnosis, prognosis, and wound care treatment.
• As a leader, provides oversight, assistance and guidance to other members of the interdisciplinary wound care team to establish and provide a comprehensive approach to wound management that includes all disciplines and promotes optimum outcomes.
• Provides bedside treatments to include conservative sharp debridement, when indicated and permitted by state practice acts and facility policy.
• Independently, or in collaboration with other interdisciplinary wound care team members, develops and implements wound prevention, skin management, and wound treatment programs and provides corresponding education to patients, family members/caregivers, and facility/agency staff.
• Collaborates with other wound care professionals to promote research and assess findings to establish updated, relevant approaches to improve wound prevention and wound care practices.
• Collaborates with other wound care team members to promote the facility or agency quality improvement program.

Assistant/Associate Physician

Role: The Assistant Physician works independently or in collaboration with a physician (according to state practice acts and facility/agency policies) to lead the interdisciplinary wound care team to plan and provide care for the patient at risk of or with wound care needs. Responsibilities include but are not limited to:

• Abides by state practice acts, regulations, and laws established within the state/states of licensure, and facility or agency-based credentialing and privileging requirements to prescribe medications, order tests and treatments, and make necessary referrals.
• Independently or in collaboration with the physician comprehensively assesses and establishes wound diagnosis, prognosis, and wound care treatment.
• As a leader, provides oversight, assistance and guidance to other members of the interdisciplinary wound care team to establish and provide a comprehensive approach to wound management that includes all disciplines and promotes optimum outcomes.
• Provides bedside treatments to include conservative sharp debridement, when indicated and permitted by state practice acts and facility policy.
• Independently, or in collaboration with other interdisciplinary wound care team members, develops and implements wound prevention, skin management, and wound treatment programs and provides corresponding education to patients, family members/caregivers, and facility/agency staff.
• Collaborates with other wound care professionals to promote research and assess findings to establish updated, relevant approaches to improve wound prevention and wound care practices.
• Collaborates with other wound care team members to promote the facility or agency quality improvement program.

Doctor of Podiatric Medicine (DPM)

Role: The DPM works independently or in collaboration with other team members (according to state practice acts and facility/agency policies) to lead the interdisciplinary wound care team to plan and provide care for the patient at risk of or with wound care needs. Responsibilities include but are not limited to:

• Abides by state practice acts, regulations, and laws established within the state/states of licensure, and facility or agency-based credentialing and privileging requirements to prescribe medications, order tests and treatments, and make necessary referrals.
• Independently or in collaboration with the team members comprehensively assesses and establishes lower extremity wound diagnosis, prognosis, and wound care treatment.
• As a leader, provides oversight, assistance and guidance to other members of the interdisciplinary wound care team to establish and provide a comprehensive approach to wound management that includes all disciplines and promotes optimum outcomes.
• Provides bedside treatments to include conservative sharp debridement, when indicated.
• Independently, or in collaboration with other interdisciplinary wound care team members, develops and implements wound prevention, skin management, and wound treatment programs and provides corresponding education to patients, family members/caregivers, and facility/agency staff.
• Collaborates with other wound care professionals to promote research and assess findings to establish updated, relevant approaches to improve wound prevention and wound care practices.
• Collaborates with other wound care team members to promote the facility or agency quality improvement program.

Care coordination: treat the whole patient

According to the Centers for Medicare/Medicaid (CMS): “Wound care involves the evaluation and treatment of a wound, including identifying potential causes of delayed wound healing and the modification of treatment when indicated. Wound evaluations may require a comprehensive medical evaluation, vascular evaluation, orthopedic evaluation, functional evaluation, metabolic/nutritional evaluation, and a plan of care” (CMS, L37166).[37]The standard of care calls for a team to work together to ensure all elements are evaluated on an ongoing basis.

Appropriate referrals: Timely consultation with pain specialists, dietitians, or other providers based on an individual's symptoms and assessed needs improves patient outcomes and decreases the risk of legal problems Refer to specialists when an assessment indicates it will be beneficial. Specialists that wound patients are frequently referred to include: 

• Podiatry, Surgeons, Infectious Disease, Vascular, Hyperbaric Medicine
• Physical, Occupational, Lymphedema Therapist
• DME/stocking fitters
• Nutritionist
• Diabetes educator
• Pain management
• Social services
• Home Care

Risk Assessments: Perform and Follow Through on Findings

Risk Assessments for pressure ulcers, malnutrition, neuropathy, depression and suicide risk, falls, compromised vascular flow to the lower extremity are routinely performed in the initial visit (s) and as part of assessment and evaluating a new patient with wound.

For "At Risk" patients, policies must mandate ordered, implemented, and evaluated follow-up interventions to avoid liability arising from deterioration due to lack of intervention orders, undocumented implementation, or ineffective follow-up. Patient adherence should be documented, including barriers and interventions for non-adherence. 

Infection Diagnosis and Management

Failure to assess, identify, and treat infection in a wound lead to the delay in care, deterioration of wound, sepsis, and death. Standard wound care includes assessing for and recognizing the signs and symptoms of infection. The provider is expected to recognize, diagnose, and treat wound infections timely and appropriately

Protocols for identifying, diagnosing and managing infection. See topic "Wound Infection"

Foreign Body

Missed foreign bodies frequently result in physician malpractice litigation. Wound care is the subject of 5-20% of lawsuit claims against emergency medicine (EM) physicians, resulting in 3-11% of monetary awards. [38]

• Tunnels: 
• • Packing Removal
  • Tunnel Monitoring
• Negative Pressure Wound Therapy (NPWT)
• • No dressing is left retained or embedded into fresh granulation tissue.
  • Dressing count upon NPWT application, removal and dressing change.
• Non-healing surgical wounds: assess for retained surgical materials.
• Non-healing trauma wounds: assess for dirt, wood, gravel, bone chards, glass, and other debris that may be embedded as a result of the traumatic injury.