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  1. Kayser-Jones, Jeanie S. PhD, RN, FAAN
  2. Beard, Renee L. PhD
  3. Sharpp, Tara J. PhD, RN


This case study of the care received by a terminally ill nursing home resident in his late 80s describes the many organizational and clinical factors that led to the progression of his pressure ulcer from stage II to stage IV. The patient suffered weight loss, an increase in tissue load, and deterioration of the wound and finally died in pain with a large stage IV pressure ulcer that exposed his coccyx. The authors examine the ethical aspects of the case and explore the ways in which inadequate staffing, staff education, and supervision contributed to insufficient help with meals, infrequent and improper repositioning, and unrelieved pain. To hear AJN editor-in-chief Diana J. Mason's audio interview of Jeanie S. Kayser-Jones, in which the coauthor discusses the ethical dilemmas she encountered while conducting research in this case, go tohttp://www.ajnonline.comand click on "Podcasts."