Case Types

(Pressure Injuries)

Bedsores are commonly referred to by their more formal medical terms such as pressure injuries, pressure sores, pressure ulcers, or decubitus ulcers. These terms all mean the same thing. It is estimated that 2.5 million people get bedsores each year.

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What are Bedsores?

Bedsores are injuries to the skin and the tissue under the skin. These sores or ulcers are caused by continuous pressure to the skin. When a person remains in the same position, the skin begins to break down causing an ulcer to form. Although we do not often notice it, we shift our bodies frequently throughout the day. Many nursing home residents are unable to do this on their own, however. It becomes the nursing home’s responsibility to make sure the resident is being turned and repositioned in their bed and wheelchair. 

There are certain areas of the body where bedsores are most likely to occur. These areas most at risk are the lower back and tailbone (called the sacrum and coccyx), heels, ankles, and hips. 

Nursing homes must protect these areas of the body to prevent bedsores from forming.

Who is at Risk for Bedsores?

stages of pressure ulcer in nursing home residents

Many nursing home residents are at risk for developing bedsores. Residents who are most at risk of developing bedsores are people who have trouble changing positions in bed or in a wheelchair. The most common risk factors for bedsores are:

  • Immobility: It does matter the reason why a person has difficulty moving in bed, if they cannot regularly reposition themselves, they are at risk of developing a bedsore. The most common reasons people have poor mobility at nursing homes is because of generally poor health, advanced dementia, weakness, complications of a stroke, and spinal cord injuries.
  • Wheelchairs: If a person spends much of their time in a wheelchair, they are at an increased risk of developing a bedsore.
  • Incontinence: When the skin is exposed to moisture, it becomes weak and vulnerable. Bladder and bowel incontinence are risk factors for developing a bedsore.
  • Lack of sensory perception: If a person cannot sense that they have been in the same position or cannot feel that there has been prolonged pressure on an area, it can result in the person not turning and repositioning when they should. Spinal cord injuries, neurological disorders, diabetes, and other conditions that decrease sensation increase the risk of developing bedsores.
  • Poor nutrition and hydration: Healthy skin requires sufficient calories, protein, minerals, vitamins, and fluids. If a person is dehydrated or malnourished or has health conditions that prevent them from processing nutrients, they are at risk of developing a bedsore.
  • Medical conditions affecting blood flow: Healthy skin requires adequate blood flow. Certain health problems, such as diabetes or vascular disease, can increase the likelihood of developing a bedsore.
  • Medical devices: Casts, splints, and other medical devices or equipment can put pressure on part of the body. If that medical device places pressure directly on the body and there are inadequate steps to pad, protect, or remove the device, a bedsore can form.

How do Bedsores Form?

Bedsores occur because of a combination of factors. The most common causes of bedsores are:

  • Pressure: To be healthy, skin requires an adequate amount of blood flow. Blood is necessary to deliver oxygen and nutrients to the skin and surrounding tissues. Without adequate blood flow, the tissue can be damaged and eventually die. For people with limited mobility or people with sensory problems, pressure tends to remain on one area of the body. These areas tend to be the lower back and tailbone (called the sacrum and coccyx), heels, ankles, and hips. The nursing home must protect these areas from prolonged pressure. They do this by frequently turning and repositioning the resident, keeping the heels off the bed by “floating” them or using protective boots, and using devices such as foam pads to adjust the resident.
  • Friction: Friction occurs when two surfaces have rub against each other and do not slide easily. When a person’s skin rubs against clothing or bedding, there can be friction. This friction or rubbing can weaken the skin making it more likely to be injured. This is especially true if the skin is moist.
  • Shear: Shearing occurs when two surfaces move in opposite directions. When a bed is elevated at the head, for example, a person can slide down the bed. As the lower back or tailbone slides down the bed, there is a shearing force on the skin over the tailbone. This friction can weaken or tear the skin causing a bedsore.

Are Bedsores A Sign of Abuse and Neglect?

Bedsores are often a sign of nursing home abuse and neglect. Any significant bedsore should be investigated for potential nursing home liability. Additional signs of neglect and abuse include nursing homes not treating the wound, not discussing the wound with family members, and allowing the wound to become infected.

Are Bedsores Preventable?

The vast majority of bedsores are preventable with reasonable care. There are some rare instances where bedsores may be considered “clinically unavoidable” or unpreventable. However, bedsores are only considered unavoidable if the nursing home has taken all reasonable steps to prevent the development of  bedsores and the resident still develops them. This typically only happens when a person is receiving end of life care and actively in the process of dying. Nursing homes often claim that bedsores are unpreventable, but that is not true. 

How do Nursing Homes Prevent Bedsores?

Nursing homes are required to assess residents when they are admitted to the nursing home to determine their risk of developing bedsores. Based on the results of these assessments, the nursing home must create a plan to prevent a resident from developing pressure injuries. Because all residents are different, the plan must be specific to the individual resident’s needs and risk factors. All plans to prevent bedsores should include:

  • Reduce Pressure: The most reliable way to prevent the development of bedsores is for nursing homes to ensure that residents do not remain in the same position for prolonged periods of time. If a person cannot reposition themself in bed, then the nursing home staff must provide whatever assistance is needed to make sure the resident does not remain in one spot. This can include staff physically turning the resident in bed or using devices, such as foam pads, to adjust the resident. In addition to moving the patient, they must also prevent the heels from remaining on the bed. They can do this by placing a pad or pillow under the calf to “float” the heels so they remain off the bed. They can also use special padded boots to protect the heels.
  • Clean: When the skin is exposed to feces, the skin can become weakened and more vulnerable to bedsores. Staff must frequently toilet residents who need assistance using the bathroom and check and change incontinent residents so they are not forced to remain in their waste.
  • Dry: Staff must frequently check residents to make sure that the skin is not moist. Moisture from urine or sweat can weaken the skin making it more likely to open.
  • Nutrition: Nursing homes control the diets of their residents and must monitor the amount of food they eat. The nursing home must take appropriate steps to make sure that the resident is getting adequate nutrition to maintain healthy skin. If a resident does begin to show signs of weight loss or malnutrition, the nursing home must alter the resident’s diet to prevent further weight loss and promote weight gain.
  • Reduce Shearing and Friction: If the head of the bed is kept at a steep angle, the skin experiences shearing and friction. By lowering the angle of the back of the bed, less shearing force and friction is placed on the skin.
  • Inspect Skin Daily: Nursing staff must check a patient’s skin daily to identify whether there are any signs that a bedsore is developing. If there are early signs that a bedsore is developing, the skin can usually be treated and will heal. If staff neglect to inspect the resident’s skin, bedsores can worsen quickly and cause irreversible damage. 

Are Bedsores Dangerous?

In addition to being extremely painful, bedsores can cause life threatening complications. The most common complication is infection. When bedsores become infected, they can lead to multiple life threatening complications including necrotizing fasciitis (flesh eating disease), sepsis, and septic shock.

Nursing homes must take all appropriate steps to prevent bedsores from forming. If a person develops a bedsore, the nursing home must take all reasonable measures to treat the bedsore to prevent the bedsore from worsening. Nursing staff must also keep the skin clean and cover it appropriately to prevent bacteria from entering the wound. 

stages of bedsores in a nursing home

Bedsores are categorized in stages. Stages do not relate to the overall surface size of the wound. The stage relates to how deep the bedsore is and how much damage there is to the tissue under the skin.

  • Stage 1: With a Stage 1 bedsore, the skin and tissue is not broken. The area is red and may feel warm to the touch. In darker skin, the area may have a purple or blue tint. Stage 1 bedsores typically heal within 1 week if pressure is relieved.
  • Stage 2: With a Stage 2 bedsore, a shallow wound develops with a red or pink base under the open skin. There may also be fluid filled blisters. Stage 2 bedsores typically heal within 1 to 2 weeks with proper care.
  • Stage 3: With a Stage 3 bedsore, the open wound has penetrated the fatty layer of tissue under the skin. Stage 3 bedsores typically require more extensive treatment, including ointments and potentially surgery.
  • Stage 4: With a Stage 4 bedsore, the wound penetrates all 3 layers of skin. Muscle, tendons, and bone are exposed. A Stage 4 bedsore is considered the most severe bedsore. Stage 4 bedsores may require extensive treatments, including surgery, medications for infections, wound vacs, skin grafts, and may never heal even with the best care.
  • Unstageable: An unstageable bedsore is a wound that is covered in dead tissue (referred to as slough or eschar). Because the wound is covered, the depth of the wound cannot be determined. Therefore, it cannot be staged. Unstageable bedsores are always at least a Stage 3 or 4 under the dead tissue.
  • Deep Tissue Injury: When a bedsore is deep below the skin and cannot be seen on the surface, the presence of a bedsore is suspected.  Because the bedsore cannot be seen, it cannot be confirmed. It is referred to as a suspected deep tissue injury or DTI. The area of the skin may be dark red or purple. 

How Are Bedsores Treated?

Bedsores are treated differently depending on the stage of the wound. In many instances, the same measures that are used to prevent wounds are also sufficient to treat wounds. This is especially true with Stage 1 and 2 wounds, which can usually heal within 1 to 2 weeks with appropriate treatment.

  • Reduce Pressure: Reducing or removing pressure from the affected area prevents further skin breakdown and allows the tissue to heal.
  • Protect the Wound: Protecting the wound with medicated gauze or other special dressings encourages wound healing. It also prevents outside bacteria from entering the wound.
  • Clean: To prevent infection and worsening of the wound, nursing home staff must keep the wound clean. This includes keeping the wound free from coming into contact with feces, urine, or potentially contaminated surfaces.
  • Nutrition: Nursing homes must increase protein, calories, and nutrients to promote healing of the wound.
  • Debridement: In order to allow the wound to heal, doctors sometimes remove damaged, infected, or dead tissue in a process called a debridement. Debridement can be performed in multiple ways. In some instances, an ointment is applied that includes enzymes that break down the tissue over the wound. In other situations, doctors may need to use a scalpel to cut away the dead or diseased tissue. Depending on the amount of tissue to be removed, this can be done at the bedside or under general anesthesia in the operating room.
  • Skin Graft: In order to close an open wound, a doctor may perform a skin graft by transplanting healthy skin to the wound area.
  • Wound Vac: After a large wound has been debrided, doctors sometimes apply negative pressure wound therapy, which is referred to as a wound vac. A device is placed over the wound that decreases air pressure on the wound. This promotes wound healing and also creates a sanitary environment that prevents infection.
  • Medicine: Medicines are usually not used to treat the wound itself. However, medicines, such as antibiotics, may be used to treat infections caused by the wound. 

What are the Signs of an Infected Bedsore?

The early signs of an infected bedsores are similar to other infections. These early signs include fever and chills. Additional signs and symptoms that a bedsore is infected include:

  • Oozing pus (called purulent drainage)
  • Foul smelling odor
  • Warm and red to the touch
  • Swollen tissue on or around the wound
  • Extreme pain

If there are any signs or symptoms of an infection, nursing homes must respond immediately and provide treatment. Without treatment, infections can progress quickly and be deadly. 

Representative Cases


Bob was an 83-year-old resident of a nursing home. He walked with a cane when he entered the nursing home. However, he soon required a wheelchair. When his family visited him, they saw him in his wheelchair or his bed. He was always in the same position. When his family questioned why he was in bed or a wheelchair, staff responded that he was having a flare up of gout. His family was called from the hospital and told that he was being admitted with a Stage 4 bedsore to his lower back that was severely infected. The family was unaware of the bedsore. The hospital had to vacuum feces out of the wound. Bob continued to decline over the next several months, and ultimately died from the bedsore.


Myrtle lived at home and was doing well. She passed out at home and needed to be hospitalized for about one week. She was sent to rehabilitation to regain her strength before returning home. When in rehabilitation, her family would visit and she was often sitting in her own feces and urine. Her family complained but to no avail. She became unresponsive and was sent to the hospital where she was diagnosed with an infected Stage 4 bedsore. Her spine was visible because the wound was so large. Myrtle died within one day of being hospitalized. 


Robert was an 84-year-old resident of a nursing home. He had advanced dementia, and was unable to turn and reposition himself in bed or when in a wheelchair. He required the assistance of staff for turning and reposition to reduce pressure on the skin. Because the nursing home was severely understaffed, there were not enough people to assist Robert. When his family and friends visited, Robert was often lying or sitting in his own feces. His overall health declined until he was hospitalized with an infected bedsore on his lower back and also on his heels. He died from complications of sepsis caused by the infected wound.


Addie was an elderly resident of an assisted living facility near West Virginia. Addie was incontinent of bowel and bladder. She also needed help moving in bed. She was at high risk for developing bedsores. Addie was not an appropriate resident for an assisted living facility. She should have been in a nursing home. The facility did not turn and reposition Addie in bed like they were supposed to. They also allowed her to lay in her own urine and feces for hours. She developed a large, infected bedsore on her lower back.  The bedsore and the infection caused her death.


Susan was a 69-year-old woman who lived at home. Susan was hospitalized for five days for a urinary tract infection. She was then moved to a nursing home to receive therapy before returning home. The nursing home did not assist her with turning and repositioning. She developed a large Stage 4 bedsore to her lower back area, called the sacrum or coccyx. She was not sent to the hospital for treatment until the wound was severely infected, and she was in septic shock. She did not survive and died from septic shock while in the hospital. 

How Much is My Nursing Home Bedsore Case Worth?

Every case is unique and has to be evaluated on its specific facts. The only way to determine the value of your nursing home bedsore case is to begin an investigation.