[Cite as Triplett v. Ohio State Univ. Med. Ctr., 2011-Ohio-5994.]




                                                          Court of Claims of Ohio
                                                                                    The Ohio Judicial Center
                                                                            65 South Front Street, Third Floor
                                                                                       Columbus, OH 43215
                                                                             614.387.9800 or 1.800.824.8263
                                                                                        www.cco.state.oh.us



JOYCE TRIPLETT,                                                     Case No. 2009-03991

        Plaintiff,

        v.                                                          Judge Alan C. Travis

THE OHIO STATE UNIVERSITY
 MEDICAL CENTER,

        Defendant.                                                  DECISION


         {¶1} Plaintiff brought this action alleging medical negligence.                  The issues of
liability and damages were bifurcated and the case proceeded to trial on the issue of
liability.
         {¶2} On January 16, 2008, plaintiff presented to defendant’s emergency room
with complaints of shortness of breath.1 Plaintiff was admitted and diagnosed with
pneumonia and hypoxemia.                Plaintiff was morbidly obese, weighing more than 500
pounds, with a history of obstructive sleep apnea and being bedridden. According to
medical records, plaintiff had been discharged from an extended care facility ten days
earlier, where she had been treated for a left foot ulcer which required intravenous
antibiotic therapy.
         {¶3} Upon admission, defendant’s nursing staff conducted a “Braden Scale”
assessment to determine whether plaintiff was at risk for skin breakdown. According to
medical literature and defendant’s policy guidelines, any patient who scores 18 or less
on the Braden Scale is at risk for skin breakdown. Plaintiff’s score was 14. When she
was examined, it was noted that plaintiff had pressure ulcers on both of her heels,
multiple open areas on the skin of her lower extremities, and a wound on the back of

1
All dates referred to herein pertain to the year 2008.
her left thigh. A wound management team consult was ordered to examine the ulcer on
plaintiff’s left foot, which had previously been treated with a “wound vac.” Nurse Mary
Merrill examined plaintiff on January 17 and noted that she would return with Dr.
Gordillo, a plastic surgeon, the following day. Plaintiff was then classified as a wound
management team patient.
       {¶4} When plaintiff’s respiratory status worsened, she was intubated and moved
to the Intensive Care Unit (ICU). Plaintiff was sedated, placed on a feeding tube and a
ventilator, and underwent intensive respiratory therapy, which included high levels of
supplemental oxygen, Positive End Expiratory Pressure (PEEP), and treatment with
nitric oxide. Plaintiff remained on a ventilator for more than two weeks. On February 4,
plaintiff was extubated but remained on oxygen therapy with a breathing mask; on
February 9, she was moved from the ICU to the step-down unit; and on February 13,
she was discharged to the Broadview Nursing Care Facility, where she was diagnosed
with a Stage IV pressure ulcer on her left hip/buttock/ischium area.
       {¶5} Plaintiff’s claim of negligence relates exclusively to the skin wound on her
left hip/buttock/ischium area. Plaintiff contends that the wound originated as a pressure
ulcer and that the care she received from defendant’s staff fell below the accepted
standard of care when they failed to consistently provide the care necessary to prevent
or reduce skin breakdown, including repositioning or turning her every two hours.
Defendant asserts that its nursing staff met the standard of care and that plaintiff’s skin
wound was unavoidable.
       {¶6} “There is no presumption of malpractice from the mere fact of injury.”
Turner v. Children’s Hosp., Inc. (1991), 76 Ohio App.3d 541, 548, citing Ault v. Hall
(1928), 119 Ohio St. 422, 429. “In order to establish medical malpractice, it must be
shown by a preponderance of evidence that the injury complained of was caused by the
doing of some particular thing or things that a physician or surgeon of ordinary skill, care
and diligence would not have done under like or similar conditions or circumstances, or
by the failure or omission to do some particular thing or things that such a physician or
surgeon would have done under like or similar conditions and circumstances, and that
the injury complained of was the direct and proximate result of such doing or failing to
do some one or more of such particular things.” Bruni v. Tatsumi (1976), 46 Ohio St.2d
127, paragraph one of the syllabus.
          {¶7} Plaintiff’s expert, Ilene Warner-Maron, Ph.D., R.N., testified that she is
certified in both wound care and bariatric nursing, and that she currently practices with
Alden Geriatric Consultants, Inc., where she provides expertise in the field of
administration and nursing interventions to patients in home health care, nursing homes
and the geriatric community.
          {¶8} Warner-Maron stated that a pressure ulcer is an area of skin destruction
caused by pressure over a bony area, whereby the blood flow is interrupted and the
skin dies.     She noted that the Braden Scale sets forth the following six factors to
consider in assessing a patient’s risk for developing pressure ulcers: 1) sensory
perception, or ability to respond to pressure-related discomfort; 2) the degree to which
skin is exposed to moisture; 3) patient’s physical activity level; 4) patient’s ability to
change and control body position; 5) nutritional status; and 6) effect of friction and shear
as a potential problem. Warner-Maron testified that there are four stages of pressure
ulcers:     Stage I is a red area that does not “blanch” when pressed; Stage II is a
superficial tear in either the dermis or the epidermis which can also include a fluid-filled
blister; Stage III is a shallow crater through the subcutaneous layer of skin; and Stage
IV is significant tissue destruction through the fascia or muscle, which may include bone
exposure. Warner-Maron defined a skin tear as a superficial tear to the upper layers of
skin.
          {¶9} Warner-Maron testified that the medical records reflect that a wound on
plaintiff’s left posterior thigh existed on January 17, but that there was no documentation
of a skin tear in that area until 11 days later. In the step-down unit, beginning on
February 9, a large skin tear is noted daily from February 9 to February 12, which at
times is described as a Stage II ulcer. Warner-Maron stated that in her opinion, the
initial Braden Scale assessment identified that plaintiff was at high risk for pressure
ulcers, but that defendant’s nursing staff did not implement the appropriate
interventions.     Warner-Maron further stated that the use of a bariatric bed was
appropriate, but questioned whether an adequate support surface was provided.
Warner-Maron also opined that the standard of care required turning and repositioning
plaintiff every two hours. Warner-Maron stated that inasmuch as the repositioning of
plaintiff occurred every 2 to 4 hours, defendant’s employees failed to meet the standard
of care.     Warner-Maron found no evidence that the wound specialist knew about
plaintiff’s ischial wound because she was consulted solely for the foot wounds; that
weekly measurements of the wound, including descriptions and staging, were not
charted; and that if necrotic material existed inside the wound, treatment with
Xenaderm, an ointment, would not have been appropriate. Warner-Maron also opined
that the wound was a pressure ulcer because it originated over a bony area, the
ischium. According to Warner-Maron, the wound was erroneously categorized as a skin
tear when, in fact, it originated as a Stage II pressure ulcer that developed into a severe
pressure ulcer with necrotic tissue. On cross-examination, Warner-Maron stated that
skin tears can occur in the absence of negligence, and that Xenaderm was an
appropriate treatment for skin tears.
        {¶10} Mary Merrill, R.N., testified that she was a member of defendant’s wound
management team which consists of certified wound, ostomy, and continence nurses
who work in collaboration with a plastic surgeon. Merrill testified that the standard
protocol for pressure ulcers is to keep skin clean and dry, to turn and reposition the
patient frequently, to provide pressure relief with a low air loss bed, and to maximize
nutrition. Merrill added that linens are changed, at a minimum, daily, but many times
linens are also changed every time that a patient is turned. Merrill noted that she was
aware of plaintiff’s ischial wound because the medical records show that she ordered
Xenaderm to be applied to the skin around that wound as well as to the wounds on
plaintiff’s feet.
        {¶11} Leandra Towns, R.N., Emily Mowry (nee Jones), R.N., Dusty Kellar, R.N.,
and Alicia Rendon, R.N., testified that they cared for plaintiff at various times during her
stay at defendant’s hospital, and that the nursing notes reflect the care that they
provided her during that time, including Braden Scale assessments, repositioning,
pressure relief aided by the use of a specialty bed, and treatment of plaintiff’s wounds.
They agreed that due to plaintiff’s weight, the assistance of at least four people was
required to physically turn her.
       {¶12} Leroy Essig, M.D., testified that he was plaintiff’s primary physician in the
ICU. Dr. Essig explained that while turning is an important part of helping to prevent
pressure ulcers, in plaintiff’s case, there were some limitations to turning her. Dr. Essig
noted that any time patients on a ventilator are turned, there is a risk that they can lose
hardware such as central lines or breathing tubes, which can be life-threatening. Dr.
Essig further stated that patients with nasogastric tubes who are at risk for ventilator-
associated pneumonia are kept in a semi-upright position to prevent aspiration or further
ventilator-associated pneumonia, which can also limit turning.
       {¶13} Defendant’s expert, Diane Krasner, Ph.D., R.N., testified that she is
licensed   in   Maryland     and    Pennsylvania,    and    that     she   has   practiced
wound/ostomy/continence nursing since 1985. According to Krasner, by definition, skin
tears usually occur on legs, shins, hands, and arms, while pressure ulcers occur over a
bony prominence. The causes of skin tears are a thinning of the skin, including saggy
skin, and a moist environment. She added that the friction of turning someone can also
cause a skin tear. Krasner noted that severe edema and incontinence also heighten the
risk for skin breakdown; that any acute wound can progress to a chronic wound; and
that she has observed skin tears that evolve into pressure ulcers.
       {¶14} Krasner stated that inasmuch as plaintiff was immobile, morbidly obese,
edematous, and incontinent with leakage of stool, she was at high risk for skin
breakdown. After a review of the medical records and the depositions of the treating
nurses, Krasner opined that the initial wound, as described in the records, originated as
a skin tear, and that the appropriate treatment for such a wound was to keep it moist,
since it occurred over a fleshy part of the body and not over a bony prominence.
Krasner stated that the ischial wound was most likely a buttocks injury caused by
plaintiff’s own weight. Krasner opined that defendant’s policy of turning a patient every
2 to 4 hours while on a specialty bed (Plaintiff’s Exhibit 3) was based upon 2003
guidelines and was reasonable.       In sum, Krasner opined that the skin tear was
unavoidable, because despite the fact that defendant’s nursing staff implemented
appropriate interventions including pressure relief, the use of a bariatric bed,
incontinence management, skin care, and repositioning, plaintiff’s co-morbidities,
including her respiratory status and obesity, hindered improvement of the ischial wound.
      {¶15} As with virtually all cases involving claims of medical malpractice, this case
is based upon the testimony and professional opinions of medical experts. It is not
unusual for experts in the medical field to disagree on the standard of care in a
particular medical presentation, or whether that standard of care was met. Sincere
disagreement as to whether medical treatment met the standard of care in a particular
case is understandable.    To prevail, plaintiff’s evidence must preponderate; that is,
plaintiff must demonstrate that it is more likely than not that defendant committed
medical malpractice.   Thus, the question in this case is whether the evidence and
testimony of expert witnesses presented by plaintiff is more persuasive or of greater
probative value than the evidence and testimony presented against it. Upon review, the
court cannot say that plaintiff’s evidence was more persuasive, or of greater probative
value than the evidence opposed to it.
      {¶16} The court finds that the testimony of Nurse Krasner was more persuasive
than that of Nurse Warner-Maron. Indeed, the medical records reflect that plaintiff’s
injury was repeatedly classified as a skin tear, and that the appropriate treatment for
skin tears was implemented. The court finds that plaintiff has failed to prove by a
preponderance of the evidence that the standard of care required that she be
repositioned every two hours, or that the failure to do so was the proximate cause of
plaintiff’s ischial wound. The greater weight of the evidence shows that defendant’s
nursing staff met all applicable standards of care in the treatment of plaintiff and that
despite the efforts to minimize skin breakdown, plaintiff’s ischial wound worsened.
      {¶17} For the foregoing reasons, the court finds that plaintiff has failed to prove
any of her claims by a preponderance of the evidence and, accordingly, judgment shall
be rendered in favor of defendant.
                                             Court of Claims of Ohio
                                                                       The Ohio Judicial Center
                                                               65 South Front Street, Third Floor
                                                                          Columbus, OH 43215
                                                                614.387.9800 or 1.800.824.8263
                                                                           www.cco.state.oh.us



JOYCE TRIPLETT,                                       Case No. 2009-03991

       Plaintiff,

       v.                                             Judge Alan C. Travis

THE OHIO STATE UNIVERSITY
 MEDICAL CENTER,

       Defendant.                                     JUDGMENT ENTRY


        {¶18} This case was tried to the court on the issue of liability. The court has
considered the evidence and, for the reasons set forth in the decision filed concurrently
herewith, judgment is rendered in favor of defendant. Court costs are assessed against
plaintiff. The clerk shall serve upon all parties notice of this judgment and its date of
entry upon the journal.



                                         _____________________________________
                                         ALAN C. TRAVIS
                                         Judge


cc:
Daniel N. Abraham                           Jennifer A. Adair
David I. Shroyer                            Karl W. Schedler
536 South High Street                       Assistant Attorneys General
Columbus, Ohio 43215                        150 East Gay Street, 18th Floor
                                            Columbus, Ohio 43215-3130

Filed October 6, 2011
To S.C. reporter November 18, 2011
