Nursing Home Negligence Law: Pressure Ulcers

One of the most frequent complaints we hear from potential clients is that their mom or dad contracted pressure ulcers (also known as bedsores) in a nursing home. If your loved one has developed a pressure ulcer while in nursing home care, you’re likely dealing with a mix of anger, confusion, and heartbreak. Medical literature and legal standards demonstrate that most pressure ulcers in nursing homes are entirely preventable with proper care. When they occur, they often signal serious neglect that can have devastating consequences for elderly residents.

The following are tips families can use to avoid pressure ulcers in the first place, and decide when to call a nursing home negligence lawyer.

Understanding Pressure Ulcers: More Than Just “Bedsores”

Pressure ulcers, also known as bedsores, pressure injuries, or decubitus ulcers, are injuries to the skin and underlying tissue caused by prolonged pressure on the skin over bony areas like the tailbone, hips, heels, and back of the head. What many families don’t realize is how quickly these injuries can progress from minor skin irritation to life-threatening infections.

The Four Stages of Pressure Ulcers

There are four stages to pressure ulcers. Sadly, law firms can typically only assist families when the ulcers have progressed to the worst stages – 3 or 4. Below is a summary of the four stages of pressure ulcers.

• Stage 1: Non-blanchable redness of intact skin

• Stage 2: Partial thickness skin loss presenting as a shallow open ulcer or intact/ruptured blister

• Stage 3: Full thickness tissue loss with visible subcutaneous fat but no exposed bone, tendon, or muscle

• Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle - often life-threatening

The progression from Stage 1 to Stage 4 can happen rapidly without proper intervention. According to recent studies, between 2-28% of nursing home residents develop pressure ulcers, with many cases being entirely preventable through appropriate care protocols.

Standard of Care

In civil cases against nursing homes, the suing party must prove that the nursing home and its staff breached the standard of care. The “standard of care” refers to the level of care, skill, and diligence that a reasonably prudent professional in a given field would exercise under similar circumstances. It’s a benchmark used to evaluate whether someone’s actions meet the expected level of competence and responsibility, often in the context of negligence or malpractice claims.

In the District of Columbia and Maryland, the standard of care is on a national scale, i.e., what nursing homes across the nation would do under similar conditions. Virginia courts dictate that the standard of care in Virginia cases is local. In other words, the jury will hear what local standard practices are for preventing pressure ulcers.

The Code of Federal Regulations (CFR) addresses pressure ulcers, also referred to as pressure injuries or bedsores, primarily in Title 42, Part 483, Section 25(b), which covers Quality of Care in Long Term Care Facilities. These regulations, often referenced by their “F-Tag” (F686 in the CMS State Operations Manual), require nursing homes to:

• Prevent pressure ulcers: Facilities must ensure residents who enter without pressure ulcers do not develop them, unless it’s clinically unavoidable.

  • This includes identifying residents at risk, implementing individualized interventions like repositioning, using pressure-redistributing devices, maintaining skin hygiene, and ensuring adequate nutrition and hydration.

  • Facilities should also address any adverse drug reactions that may worsen a resident's risk of developing pressure ulcers

• Treat existing pressure ulcers: If a resident develops a pressure ulcer, the facility must provide necessary treatment and services to promote healing, prevent infection, and prevent new ulcers.

  • This involves cleaning the wound, applying appropriate dressings, and potentially removing dead tissue.

  • Infection control protocols are crucial, along with monitoring for healing or worsening of the wound.

• Documentation and assessment: Facilities must conduct comprehensive assessments of residents to identify risks and develop care plans.

  • This includes documenting ulcer characteristics like size, depth, and the presence of drainage or odor.

• Staff training and competency: All staff involved in pressure ulcer care must be adequately trained and demonstrate competency in skin assessments, risk factor recognition, repositioning techniques, and wound care management.

• Resident rights: Residents have the right to be informed about their care, including prevention and treatment options, and can participate in care planning and refuse certain treatments. 

Important Considerations:

• “Unavoidable” Pressure Ulcers: An ulcer is considered unavoidable if the facility demonstrates they have evaluated the resident's condition, implemented appropriate interventions, monitored their effectiveness, and revised the approach as needed.

• Non-compliance: Failure to meet these regulations can lead to citations, fines, and legal consequences for the facility.

• Pressure Injury Staging: While not explicitly detailed in the CFR snippet provided, pressure injuries are staged according to the extent of tissue damage, ranging from Stage 1 (intact skin) to Stage 4 (full thickness tissue loss with exposed bone or muscle). There are also classifications for deep tissue pressure injuries and unstageable pressure injuries. 

In essence, the CFR regulations emphasize a proactive and individualized approach to pressure ulcer prevention and management in long-term care facilities, holding them accountable for providing quality care and protecting resident well-being.

States have their own regulations pertaining to the prevention of pressure ulcers.

• Virginia Code § 12 VAC 5-371-220 states that “services shall be provided to prevent clinically avoidable complications” including “pressure ulcer development.”

• D.C. Municipal Regulation 3211.1(b) requires nursing facilities to have sufficient staff to provide “proper care to minimize pressure ulcers and contractures and to promote healing of ulcers.”

• Maryland’s Code 10.07.02.18 states that nursing home residents must receive proper care to prevent pressure ulcers and deformities.

When nursing homes fail to meet these standards, they may be legally liable for negligence. In fact, Medicare considers Stage 3 and Stage 4 pressure ulcers “never events” - meaning they should never occur with proper care.

Pressure Ulcer Prevention Measures

Preventing pressure ulcers starts with regular repositioning of the patient. When a person remains in the same position for extended periods, prolonged pressure on the skin can restrict blood flow and lead to tissue breakdown. In nursing home settings, staff must reposition residents every two hours for bedridden patients and every 15 minutes for those in wheelchairs. This consistent movement helps relieve pressure on vulnerable areas like the heels, hips, and lower back, dramatically reducing the risk of ulcer formation.

Another crucial prevention strategy is frequent skin inspection. Early detection of skin changes, such as redness, warmth, or discoloration, can signal the beginning of a pressure injury. Routine skin checks, ideally performed daily by trained caregivers, allow for timely intervention before damage becomes severe. These inspections should pay special attention to bony prominences and any areas in contact with medical devices, braces, or bedding. Documenting skin assessments ensures continuity of care and helps identify patterns that may require changes in the care plan.

Proper nutrition and hydration are equally important in preventing pressure ulcers. Malnourished or dehydrated patients have thinner, more fragile skin and are slower to heal from minor injuries. A balanced diet rich in protein, vitamins (especially A and C), and minerals like zinc helps maintain healthy skin integrity. Nursing home staff should ensure that residents are eating adequately and drinking enough fluids. In cases where patients are unable to feed themselves or have dietary restrictions, registered dietitians should be involved in creating individualized nutritional plans.

Finally, support surfaces, such as specialized mattresses, cushions, and overlays—can significantly reduce pressure on the skin. These devices are designed to redistribute weight and reduce friction and shear, which are common contributors to ulcer development. Pressure-relieving mattresses or mattress toppers made from foam, gel, or air are often prescribed for high-risk patients. Additionally, proper positioning and elevation techniques (e.g., using pillows to offload pressure from heels) complement the use of these surfaces and contribute to a comprehensive prevention strategy.

The Human Cost: Pain, Suffering, and Lost Dignity

Beyond the legal implications, pressure ulcers inflict tremendous suffering on residents. Advanced stage ulcers cause excruciating pain, disfigurement, and can lead to:

• Serious infections including sepsis

• Bone infections (osteomyelitis)

• Multiple painful surgeries and debridement procedures

• Prolonged hospitalization

• Death (over 60,000 deaths annually are linked to pressure ulcer complications)

For families, watching a loved one endure this preventable suffering while paying for "care" can be emotionally devastating.

Legal Compensation: Holding Facilities Accountable

When pressure ulcers result from negligence, families have legal recourse to seek compensation for:

Economic Damages

• Medical expenses for ulcer treatment

• Hospital stays and surgical procedures

• Rehabilitation and wound care costs

• Transfer to higher-level care facilities

Non-Economic Damages

• Pain and suffering endured by the resident

• Emotional distress for family members

• Loss of quality of life

• Loss of companionship (in wrongful death cases)

Settlement Amounts: What Cases Are Worth

Recent data shows that pressure ulcer lawsuit settlements and verdicts vary significantly based on case circumstances:

• Donaway v. Halifax Reg'l Long Term Care, Inc, 2022 Jury Verdicts LEXIS 13425 (May 2023) - Ida Donaway, 86, was admitted to The Woodview nursing home for four months. At the time of her admission, she suffered from speech issues and left hemiparesis. While at the facility, she developed a Stage IV sacral pressure ulcer that required two surgical debridements. She later developed another pressure ulcer on her heel and was transferred to another nursing home following a hospitalization. She died three months later and is survived by her two daughters. The jury awarded $1.4 million in noneconomic damages, approximately $100,000 for medical and funeral expenses, and prejudgment interest.

• Plaintiff v. Hospital, Virginia Lawyers Weekly (Feb. 19. 2024) - Plaintiff’s decedent was hospitalized following a cardiac procedure and sustained a sacral pressure injury that went unrecognized until it reached stage 4. Plaintiff’s experts contended that defendant’s employees failed to turn and reposition the decedent, who was at a high risk of developing a pressure injury, for several weeks. Defendant’s experts contended that the decedent had been turned and repositioned during occupational and physical therapy sessions. Plaintiff’s counsel used billing records to effectively cross-examine these experts. Plaintiff’s decedent was survived by a spouse of 54 years and two adult children. The case settled for $1.1 million.

• Doe v. Woe, 2019 Dolan Media Jury Verdicts LEXIS 322 (March 23, 2019) – Plaintiff alleged that decedent developed a pressure injury during a stay in a nursing home and hospital, which were both defendants. The case was resolved for $375,000 at mediation with Hon. F. Bradford Stillman.

• Plaintiff v. Hospital, 2016 Dolan Media Jury Verdicts LEXIS 102 (July 11, 2016) – Patient who was being treated for respiratory failure developed a stage IV sacral wound, which became infected and required multiple surgical debridements. The patient died later from unrelated causes. The case settled for $575,000.

While the above represent significant victories for plaintiffs, there have been several defense verdicts over the years. Plaintiffs do not prevail in every circumstance and it is important to know that a plaintiff’s success depends on the individual factors involved in the specific case at issue.

Building a Strong Case: Evidence That Matters

Successful pressure ulcer cases typically involve:

Medical Evidence:

• Complete medical records from the nursing home

• Hospital records documenting the ulcer's progression

• Photos of the pressure ulcers at various stages

• Expert medical testimony on standard of care

Care Documentation:

• Turning and repositioning schedules (or lack thereof)

• Skin assessment records

• Nutrition and hydration monitoring

• Staff training records

Facility Records:

• Staffing levels and ratios

• Prior citations or violations

• Policies and procedures for pressure ulcer prevention

• Incident reports

The Challenge: Proving Negligence vs. “Unavoidable” Ulcers

Nursing homes often defend pressure ulcer cases by claiming the injuries were “unavoidable” due to the resident's medical condition. However, research shows that the vast majority of pressure ulcers are preventable. Key factors that strengthen negligence claims include:

• Failure to follow established turning schedules

• Inadequate staffing levels

• Poor documentation of preventive care

• Delayed response to early warning signs

• Multiple facility violations or citations

When to Take Legal Action

Consider consulting with a nursing home negligence attorney if:

• Your loved one developed Stage 3 or Stage 4 pressure ulcers

• Multiple pressure ulcers developed simultaneously

• The facility failed to notify family of developing ulcers

• Treatment was delayed or inadequate

• The pressure ulcers led to infection, hospitalization, or death

• You suspect understaffing or poor care contributed to the injuries

Choosing the Right Legal Representation

Not all personal injury attorneys have experience with nursing home cases. Look for lawyers who:

• Specialize in nursing home abuse and neglect

• Have experience with pressure ulcer cases specifically

• Understand federal nursing home regulations

• Have access to medical experts in wound care

• Work on contingency fee basis (no fees unless you win)

• Have a track record of substantial settlements and verdicts

The Litigation Process: What to Expect

Investigation Phase (3-6 months):

• Medical records review

• Expert medical consultation

• Facility investigation and citation review

• Witness interviews

Filing and Discovery (12-24 months):

• Formal lawsuit filing

• Document exchange and depositions

• Expert witness preparation

• Settlement negotiations

Resolution:

• Most cases settle out of court, but there is no guarantee

• Trial if settlement cannot be reached

• Appeals process if necessary

Time Limits: Acting Quickly is Critical

Statutes of limitations for nursing home negligence cases vary by state but typically range from 1-3 years. Therefore, early action is essential. If plaintiffs do not pursue potential cases quickly, their claims may be barred by statutes of limitation.

In Virginia, in most cases, plaintiffs have 2 years from the date a nursing home resident is injured or died to file a nursing home negligence lawsuit. In Maryland, in most cases, plaintiffs have 3 years to file a nursing home negligence lawsuit from the date the injury or death occurred. In the District of Columbia, plaintiffs have 2 years from the date of death to file a wrongful death lawsuit and 3 years from the date of injury to file a negligence lawsuit against a nursing home. Importantly, there are exceptions and complexities to these rules. Therefore, it is important to contact a qualified nursing home negligence attorney about the statute of limitations.

The second reason to act quickly if you believe you have a viable nursing home negligence case is to preserve potential evidence. Evidence can disappear, staff can leave, and memories fade, making early legal action essential.

Beyond Compensation: Protecting Other Residents

Legal action serves multiple purposes beyond compensation:

• Forces facilities to improve care standards

• Provides accountability for negligent practices

• Protects future residents from similar harm

• Sends a message that neglect has serious consequences

Regulatory agencies like state health departments also rely on lawsuit outcomes to identify problematic facilities and implement corrective measures.

Moving Forward: Healing and Justice

Dealing with a loved one’s neglect is never easy, but you don’t have to face it alone. Legal action can provide:

• Financial resources for continued care and treatment

• Accountability for those responsible

• Peace of mind that you've fought for your loved one's rights

• Protection for other vulnerable residents

Remember, pressure ulcers in nursing homes are largely preventable. When they occur due to negligence, facilities must be held accountable for the pain, suffering, and financial burden they cause families.

If your loved one has suffered from pressure ulcers in a nursing home, consulting with an experienced nursing home negligence lawyer can help you understand your rights and options. Many attorneys offer free consultations and work on contingency fees, meaning you don’t pay unless your case is successful.

The road to justice may be long, but for many families, pursuing legal action provides a sense of purpose and helps ensure that their loved one's suffering was not in vain. By holding negligent facilities accountable, we can work together to improve care standards and protect vulnerable elderly residents across the country.