Pressure Ulcer Lawyers

Bed Sores And Pressure Ulcers In Nursing Homes

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Gloved hands arranging sterile gauze and wound care supplies on a tray

Federal Pressure Ulcer Rules

Federal nursing home rules in 42 CFR § 483.25(b)(1) require the facility to base care on a full assessment of each resident. That care must meet professional standards and prevent pressure ulcers. A resident should not develop one unless the resident’s clinical condition shows it was unavoidable. A resident who already has a pressure ulcer must get the treatment needed to heal it, prevent infection, and keep new ones from forming.

The CMS State Operations Manual, Appendix PP, is the guide federal inspectors use, and it defines both outcomes. CMS calls a pressure ulcer avoidable when the facility failed to do one or more of four things: evaluate the resident’s condition and risk factors, plan and carry out care that fits the resident’s needs and professional standards, monitor whether that care worked, and revise it when it did not. A pressure ulcer is unavoidable only when the facility did all four and the wound still formed. A finding that a resident is at risk does not, by itself, make a pressure ulcer unavoidable.

Pressure Ulcer Stages

Nursing homes record the stage and number of every unhealed pressure ulcer on the federal resident assessment. The stage definitions below come from the CMS MDS 3.0 Resident Assessment Instrument Manual, Section M.

  1. 1

    Persistent Redness

    Stage 1. The skin is still intact, but the pressure spot differs from nearby skin. It may feel warmer or cooler, firmer or softer, or painful or itchy. Light skin shows redness that does not fade; darker skin may show persistent red, blue, or purple hues.

  2. 2

    Shallow Open Wound

    Stage 2. Part of the skin’s thickness is lost, leaving a shallow open sore with a red-pink base. It can also look like an intact or broken blister.

  3. 3

    Full-Thickness Skin Loss

    Stage 3. The wound goes through the full skin layer. Fat may show, but bone, tendon, and muscle do not. The wound may tunnel under its edges.

  4. 4

    Bone-Deep Tissue Loss

    Stage 4. The wound exposes bone, tendon, or muscle. Dead tissue may cover parts of the wound bed, and the wound may tunnel under its edges.

  5. 5

    Unstageable Wound

    After careful cleaning, dead tissue still hides the wound bed, so staff cannot see or feel how deep the damage goes.

  6. 6

    Deep Tissue Injury

    Intact skin turns purple or maroon because the tissue underneath is damaged. Before the color change, the area may feel painful, firm, mushy, or warmer or cooler than the skin around it.

A stage does not move backward as a wound heals. The same CMS manual says clinical standards do not support reverse staging, so a Stage 4 pressure ulcer stays documented as Stage 4 until it has completely healed. A chart that shows a Stage 4 wound later coded as Stage 2 does not follow that rule.

Bed Sore Prevention

A resident’s skin assessment helps define the prevention plan, according to CMS guidance. Each part of that plan leaves a record, such as turning logs, skin checks, incontinence care notes, support-surface orders, and dietitian notes. Pressure wounds and wound odor belong with falls, weight loss, and delayed notice among the nursing home neglect warning signs a family can document during visits.

Resident Risk Factors

CMS Appendix PP lists the risk factors a facility is expected to assess: reduced mobility, conditions such as diabetes, thyroid disease, or end-stage kidney disease, drugs such as steroids that can slow healing, poor blood flow, cognitive impairment, skin exposed to urine or stool, poor nutrition or dehydration, a resident’s refusal of some care, and a pressure ulcer that healed before.

Braden Scale Scores

The CMS MDS 3.0 manual names the Braden Scale for Predicting Pressure Sore Risk as a common risk assessment tool. According to AHRQ training slides on pressure ulcer risk assessment tools, the scale scores six areas: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Each area scores 1 to 4, except friction and shear, which scores 1 to 3. Totals run from 6 to 23, and a lower total means a higher risk. AHRQ uses a score of 18 or less as the at-risk cutoff and lets a hospital or unit adjust that number.

Routine Prevention Care

Once a facility knows a resident’s risk, the routine care CMS describes can include repositioning, protecting or offloading the heels, keeping skin clean and limiting moisture (especially from stool), pressure-redistributing mattresses and cushions, non-irritating surfaces, and support for nutrition and hydration. Repositioning is, in CMS’s words, a common, effective intervention. MedlinePlus, from the National Library of Medicine, lists changing position every two hours among the ways to prevent pressure sores.

Complications From Advanced Bed Sores

Infection is the most common complication of a pressure injury, especially at Stages 3 and 4, according to the StatPearls review “Pressure Injury” on the National Library of Medicine’s bookshelf. An infected deep wound can spread to the bone (osteomyelitis) or a joint, or lead to sepsis, and those infections can be life-threatening. MedlinePlus also warns that pressure sores can cause serious infections and names them as a problem for people in nursing homes.

Advanced pressure injuries also come with a higher risk of death. The same StatPearls review reports that older patients with pressure injuries have a 3.6-fold higher death rate within 21 months than older patients without one.

Facility Pressure Ulcer Rates

CMS publishes each nursing home’s percentage of long-stay residents with Stage 2 to 4 or unstageable pressure ulcers, and that measure is part of the nursing home Five-Star Quality Rating System, according to the CMS Five-Star Technical Users’ Guide. The ratings and measures are posted on Medicare Care Compare, which replaced Nursing Home Compare on December 1, 2020. A family can search Care Compare for a facility and compare its long-stay pressure ulcer rate with nearby homes.

In 2004, about 159,000 of the 1.5 million U.S. nursing home residents (11%) had pressure ulcers of any stage, according to National Nursing Home Survey data in CDC NCHS Data Brief 14.

Nursing Home Wound Charts

A bed sore case review compares the wound chart against what the care plan required: wound stage, turning records, skin checks, nutrition, hydration, infection signs, and hospital transfer records.

  1. 1

    Risk Assessments

    Charts should show skin checks, a Braden or similar risk score, mobility, moisture, nutrition, cognition, and any prior wound history. Missing or infrequent skin checks are one of the first gaps reviewers check.

  2. 2

    Care Plan Changes

    Turning schedules, pressure-relief surfaces, nutrition care, incontinence care, and wound-nurse orders show what staff did once a resident was identified as at risk. A documented risk score with no later change to the care plan is a gap to examine.

  3. 3

    Physician Notice

    Infection, odor, drainage, fever, sepsis markers, wound debridement, a hospital admission, or delayed notice to the physician can extend a single-wound review across the resident’s entire stay. The time between when a wound was first noted and when it was reported to a physician is a central question.

Records Families Should Keep

The records created closest to the wound carry the most weight: nursing notes from when the wound was first observed, the risk assessment on file before that date, and any communication with the family or attending physician once the wound was identified. A gap in any one of those records is an early flag in a case review.

Some wounds develop despite proper care. That is why the review follows the CMS avoidable test: whether the facility evaluated the resident’s risk, put matching care in place, monitored it, and revised it when the wound changed. Public CMS provider data adds what the chart leaves out, such as the operator’s legal business name, chain, ownership, and penalties, which is how a review confirms who runs the facility before any records request goes out.

Dated Wound Photos

Save wound photos, discharge papers, medication records, and the facility’s explanations. Dated photographs let a reviewer track how a wound progressed against what the chart says the facility was doing about it during the same period.

Bed Sore or Pressure Ulcer From Nursing Home Care?

Dated wound photos, skin checks, turning records, and the facility’s explanations show how a pressure wound developed under the facility’s care. Sam Aguiar Injury Lawyers takes pressure ulcer cases as part of its nursing home neglect practice, under the Bigger Share Guarantee®. Clients always walk away with more money than the firm after medical bills, liens, and case expenses are paid. If the client’s share would ever be less than the legal fee, the firm cuts its fee. Flat contingency fee that never increases if your case goes to trial.

A free case review for a bed sore or pressure ulcer starts with a short form. Most cases qualify in under 10 minutes.

Key Takeaways

Federal rule 42 CFR § 483.25(b)(1) requires a nursing home to prevent pressure ulcers unless the resident’s clinical condition made one unavoidable, and being at risk alone does not make a wound unavoidable.
CMS publishes each facility’s rate of long-stay residents with Stage 2 to 4 or unstageable pressure ulcers, and families can check it on Medicare Care Compare.
A pressure ulcer’s stage does not move backward as it heals, so a Stage 4 wound stays charted as Stage 4 until it has completely healed.

Did a Pressure Ulcer Develop During a Facility Stay?

A bed sore that reaches an advanced stage usually leaves a trail in the wound chart, the care plan, and the turning schedule. Sam Aguiar Injury Lawyers requests those records and compares them against what the staff was supposed to do. The Bigger Share Guarantee® means your family always walks away with more than the firm after bills, liens and case costs, or the firm cuts its fee. Call today for a free case review.

Frequently Asked Questions

1What should a nursing home chart show about a pressure wound?+
The chart should show regular skin checks, a risk score such as the Braden Scale, the wound stage at each assessment, size and location over time, turning and repositioning records, nutrition and hydration notes, and any physician or wound-nurse orders.
2How common are pressure ulcers in nursing homes?+
A CDC survey found that in 2004, about 159,000 of the 1.5 million U.S. nursing home residents (11%) had pressure ulcers. CMS now publishes each facility’s percentage of long-stay residents with Stage 2 to 4 or unstageable pressure ulcers on Medicare Care Compare.
3What records should a family save if they notice a pressure wound?+
Save dated photos of the wound, the facility’s written explanations, discharge papers, and medication records. A wound-care case review works from documentation, so records should be preserved as soon as a wound is noticed.
4Does a pressure wound always mean the facility did something wrong?+
Not always. Federal rules allow for pressure ulcers that were clinically unavoidable. Under CMS guidance, a wound is unavoidable only when the facility evaluated the resident’s condition and risk factors, put matching care in place, monitored it, and revised it as needed. A finding that the resident was at risk does not, by itself, make a wound unavoidable.
5What can turn a pressure wound into a serious case review?+
Infection, odor, drainage, fever, sepsis markers, wound debridement, a hospital admission tied to the wound, or delayed notice to the physician or family about how the wound progressed can turn a pressure wound into a serious case review.
6Which prevention steps should the care plan show?+
CMS guidance describes routine prevention care that can include repositioning, protecting the heels, keeping skin clean and dry, pressure-redistributing support surfaces, and nutrition and hydration support. The chart should show those steps once a resident is identified as at risk.
7How is a pressure wound staged?+
The CMS MDS 3.0 manual uses Stages 1 through 4, plus unstageable wounds and deep tissue injuries. Stage 1 is intact skin with persistent discoloration, Stage 2 is a shallow open sore or blister, Stage 3 is full-thickness skin loss, and Stage 4 exposes bone, tendon, or muscle. Stages do not move backward as a wound heals.
8What does a Braden Scale score mean?+
The Braden Scale rates six areas: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Totals range from 6 to 23, and a lower score means a higher risk. AHRQ training materials use a score of 18 or less as the at-risk cutoff.