Nursing Home Neglect and Pressure Ulcers or Bedsores

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A client sits in my office and explains that his wife is in a nursing home. She planned to go just for rehabilitation after a knee replacement. But within weeks she had developed several bedsores.

I’ve heard a similar story too many times: The cold facts are that 1 in 10 residents will develop pressure ulcers as a resident of a nursing home.

Bedsore Definition

A pressure ulcer — also called a decubitus ulcer, or more commonly a bedsore — is a lesion that develops over a bony prominence such as the sacrum, tailbone, or heels. It’s caused by unrelieved pressure that damages the underlying tissue.

Bedsore Stages

Medical literature describes pressure sores in four stages:

  • Stage 1 involves changes in the top layer of the skin. Changes include color (redness), temperature (warm), or consistency (soft or boggy).
  • Stage 2 involves a break in the first two layers of the skin.
  • Stage 3 involves three layers of the skin.
  • Stage 4, also described as full thickness, involves the destruction of the underlying tissue.

Unstageable ulcers go through all layers of the skin. They contain infected or black eschar.

While Stage 1 and Stage 2 bedsores may heal in a few weeks or months, Stage 3 and Stage 4 bedsores are far more serious. Stage 3 and Stage 4 bedsores may require surgical, medical autolytic, or enzymatic debridement, which are different types of treatment for the removal of dead tissue. There is also a risk of infection, which can pose a risk of death.

Treating bedsores requires a team approach, with nursing staff working closely with the doctor or wound care nurse. A pressure ulcer can quickly develop into a large ulcer and can become infected if not properly cared for.

If your loved one is experiencing any forms of pressure sore, it is imperative to ensure that they receive medical attention immediately. Do not wait for a staff attendant to make this call.

Causes and Prevention

Pressure ulcers and bedsores are caused by unrelieved pressure on a bony surface like the coccyx or tailbone, hip, heel, or back of the head. This usually happens when patients or nursing home residents lie for long periods of time in one position, like on their back.

Prevention normally consists of moving residents so that they are not sitting or lying in the same position for extended periods. There are also specially-made cushions designed to help minimize bedsores.

Risk Factors for Pressure Ulcers – What Requirements are Mandated by Federal Law?

Federal law requires nursing homes to conduct an assessment of every resident on admission and at various intervals to determine their risk of developing a pressure ulcer. This assessment consists of evaluating various risk factors such as nutrition, mobility and activity, and degree of moisture exposure. If incontinence exposes a resident’s skin to frequent soaking with urine, the skin is more likely to break down and develop a ulcer. Nursing homes often use the Braden scale to assess a resident’s risk factors.

Duty of Nursing Homes

Specific federal regulations govern the care that a nursing home provides for all its residents. They include regulations specific to pressure ulcers. The regulations state that a resident who enters a nursing home without a pressure ulcer should not develop one unless it is “medically unavoidable”:

“Unavoidable” means that the resident developed a pressure ulcer even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.1

The nursing home must perform an assessment to identify a resident’s specific risk factors. Then the team must create a specific and personalized plan of care to reduce those risk factors, all of which must be documented in the chart. The care plan involves relieving pressure by requiring a plan for staff to turn and reposition at-risk residents at least every two hours. Without such precautions, a pressure ulcer may develop in a short period of time.

The cases that I see in my office often involve the failure of nursing homes to follow federal regulations and their own internal rules in both assessing a resident’s risk factors and implementing a personalized care plan.


Treating bedsores requires a team approach, with nursing staff working closely with the doctor or wound care nurse. A pressure ulcer can quickly develop into a large ulcer and can become infected if not properly cared for.

Cases and Firm Experience

I have investigated and prosecuted many cases of nursing home abuse involving the development of and failure to properly treat pressure ulcers. Please reach out to me for a free consultation to discuss the options for your loved one.

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1. Centers for Medicare & Medicaid Services, Tag F314