Pressure ulcers, also called pressure injuries or decubitus ulcers, are localized wounds to the skin and underlying tissue caused by sustained pressure over a bony prominence. They are classified under the National Pressure Injury Advisory Panel (NPIAP) staging system from Stage 1 (non-blanchable erythema of intact skin) through Stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle), with additional categories for unstageable wounds and deep tissue pressure injuries. Stage 3 and Stage 4 pressure ulcers occurring in hospitalized or long-term care patients represent a preventable nursing care failure in the vast majority of cases, and the Centers for Medicare and Medicaid Services (CMS) have recognized this by classifying hospital-acquired pressure ulcers Stage 3 and above as a never event for purposes of Medicare reimbursement.
The Standard of Care: Prevention Protocol
The clinical standard for pressure ulcer prevention in acute care and long-term care facilities is well-established. The Braden Scale is the most widely used risk assessment tool: it scores six subscales (sensory perception, moisture, activity, mobility, nutrition, and friction/shear) on a numerical scale, with lower scores indicating higher risk. Facilities are required to complete a Braden Scale assessment on admission and to reassess at defined intervals (typically every 24 hours in acute care and weekly in long-term care). A Braden score of 18 or below places the patient in a risk category that should trigger a written pressure ulcer prevention care plan.
The prevention care plan typically includes: repositioning every two hours for bed-bound patients; use of pressure-redistributing mattresses or overlays; heel float boots or wedge pillows for lower extremity patients; moisture management for incontinent patients; and nutritional consultation when the nutrition subscale indicates a deficit. The turning and repositioning schedule is the most critical element: a patient who is not turned every two hours on a documented schedule is receiving substandard care under virtually every applicable nursing standard.
Reading the Chart for Liability
The liability record in a pressure ulcer case lives in the nursing documentation. Request the complete inpatient record in its entirety, including the electronic nursing flow sheets in raw data export format rather than a PDF printout. The raw data contains every entry timestamp, every nursing note, and every flow sheet entry in the actual sequence they were created, without the formatting compression that a printed medical record summary applies.
Review the turning and repositioning log. If the patient was admitted on Monday at 8:00 a.m. and the first pressure ulcer assessment entry appears on Wednesday with a Stage 2 sacral wound, the facility must account for every two-hour turning period between admission and the wound discovery. A turning log showing entries every two hours with consistent nurse initials is a defense record; a log showing large gaps, templated repetitive entries with identical language across multiple shifts (evidence of charting by exception rather than actual observation), or no turning log entries at all is a plaintiff record.
Also review the wound care consultation notes. When a wound care nurse or wound ostomy continence (WOC) nurse is consulted, the consultation note specifies the wound stage at that date and may retrospectively describe the wound's progression. A WOC note stating that the wound has characteristics suggesting it was developing for five to seven days prior to the consultation, combined with a turning log showing gaps, is powerful evidence of when the failure began.
The Admission Skin Assessment
The admission skin assessment is essential for establishing that the pressure ulcer was hospital-acquired rather than present on admission. Most facilities complete a head-to-toe skin assessment at admission and document any pre-existing wounds, rashes, or skin breakdown. If the admission assessment shows intact skin at the sacrum and coccyx, and a Stage 3 sacral ulcer is documented three weeks later, the wound is hospital-acquired absent a credible explanation for a wound that could have developed in that location from a non-preventable cause.
The defense will sometimes argue that the pressure ulcer was unavoidable due to the patient's underlying medical condition, specifically that certain critically ill patients will develop pressure ulcers despite optimal nursing care. This argument is recognized in a narrow clinical literature but is difficult to sustain when the facility's own turning log shows gaps, the Braden Scale identified high risk and no prevention care plan was implemented, or the wound progressed from Stage 1 to Stage 4 over a period when the nursing record shows no wound care intervention.
Expert Requirements and Damages
A pressure ulcer malpractice case requires at minimum a nursing expert to address the standard of care for assessment, care planning, repositioning, and wound management, and a wound care specialist (typically a WOC nurse, a plastic surgeon, or an infectious disease physician if the wound became infected) to address the nature of the injury and causation. In cases where the wound led to sepsis, osteomyelitis, or death, an infectious disease expert and a causation expert connecting the wound to the systemic injury are also necessary.
Damages in severe pressure ulcer cases often include extensive wound care costs, plastic surgery for wound closure, amputation in cases of lower extremity wound infection, and wrongful death in cases where sepsis originating from the wound caused death. Plaintiff counsel should request the complete infection control records from the facility, including any cultures taken from the wound and any blood cultures taken during the hospitalization, which may establish that the bacteremia that caused the patient's clinical deterioration was sourced from the pressure wound. For coverage on standard-of-care nursing malpractice and care plan failures, see the medical malpractice practice section. Long-term care injury cases and nursing home litigation are addressed in the wrongful death and catastrophic injury section.