Bedsores, also known as pressure wounds, pressure ulcers, or decubitus ulcers, are a serious health condition in nursing homes that, in many circumstances, are both avoidable and preventable and could mean that your loved one is experiencing neglect by the nursing home. Often, these wounds develop due to prolonged pressure on the skin, typically in individuals with limited mobility, which then leads to skin breakdown overtime. 

Under federal and Wisconsin state federal regulations, nursing homes are legally required to take appropriate measures to both prevent and treat bedsores. 

Federal Regulations on Pressure Wounds in Nursing Homes

Federal law mandates that nursing homes receiving Medicare and Medicaid funding must provide residents with adequate care to prevent the development of bedsores.

42 U.S.C. § 483.25(b) states "(1) Based on the comprehensive assessment of a resident, the facility must ensure that (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing."

Put simply, nursing homes must ensure that a resident who enters a facility without a bedsore does not develop a bedsore unless it is unavoidable; if a resident does develop a bedsore at the nursing home or has a bedsore on admission, then the nursing home must promote healing and prevent infection; and the nursing home must prevent the development of new or additional bedsores. 

Stages of Pressure Wounds

Bedsores progress through four stages, each increasing in severity:

[from left to right: stage 1, stage 2, stage 3, stage 4] Photographs from National Pressure Injury Advisory Panel (NPIAP).

Stage 1: Early Warning Signs

A stage 1 pressure wound occurs when the skin is still intact but may appear red and non-blanching, meaning that the particular area of skin does not turn white when pressure is applied to it. It may also include changes in skin temperature, e.g., feeling warmer in that area. In darker skin tones, a stage 1 bedsore can appear with persistent blue and purple hues. 

Stage 2: Skin Damage Begins

A stage 2 pressure wound presents as a shallow open sore or blister, meaning the skin breaks and a shallow wound develops with a red or pink surrounding wound bed. A stage 2 bedsore may also present as either an intact blister or open/ruptured blister. At this stage, the outer layer of the skin (epidermis) is broken, exposing the underlying layer (dermis).  

Stage 3: Skin and Tissue Damage 

By stage 3, the wound has extended through the dermis into deeper layers of tissue. Fat may be exposed, and the wound appears as a deep crater. At this stage, bone, tendon, or muscle is not exposed. There may be undermining, which is where the tissue beneath the visible edges of a wound has eroded and so the damage may be larger than what appears on the surface. There also may be tunneling, which is exactly what it sounds like -- a narrow passageway that extends from the surface of the wound deeper into the surrounding tissue, creating a tunnel-like structure. A stage 3 pressure wound may also have a layer of white or yellow dead tissue on the surface of the wound called slough. 

There should be significant concerns for infection with a stage 3 wound. Due to the depth of the wound and the possibility of both undermining and tunneling, a stage 3 bedsore exposes deeper tissue layers, which can impede healing and create dead space where bacteria can thrive. 

Stage 4: Severe and Life-Threatening

Stage 4 pressure wounds are the most severe, extending into muscle, tendons, and even bone. This means that damage extends through all layers of the skin. At this stage, the wound often includes undermining, tunneling, and a foul smell. There may be either slough present or a layer of dead, dry, and hardened crusty covering on the wound known as eschar -- these are known as necrotic tissue. A stage 4 bedsore causes severe pain for residents and has a high risk of serious infections, such as osteomyelitis (bone infection) or sepsis. 

Treatment for a stage 4 pressure wound involves extensive medical care, potentially including surgery, skin grafts, wound debridements (the removal of dead/unhealthy tissue from a wound to promote healing), and antibiotics. Even despite extensive medical care, a stage 4 pressure wound can lead to death. 

For residents in nursing homes, a stage 4 pressure wound is often indicative of nursing home neglect, as proper intervention and early intervention should typically stop wounds from progressing to this stage.

Other Pressure Injuries

There are two other notable pressure injuries - unstageable and deep tissue.

Unstageable pressure injuries involve skin and tissue loss where the extent of tissue damage cannot be determined because it is blocked by slough or eschar (that is the dead and sometimes crusty tissue that layers over the surface of the wound, also called necrotic tissue). To properly stage an unstageable wound, the necrotic tissue may be removed and, often times, a stage 3 or stage 4 pressure wound will be revealed.  

A deep tissue pressure injury, also called a DTI or DTPI, often starts as a dark purple, maroon, or deep red area on the skin, almost like a bad bruise. Unlike a regular bruise, though, the skin might feel firm, mushy, warm, or cooler than the surrounding area. The skin generally remains intact, meaning there is no open wound, or a blister filled with dark blood can form in some cases. Like a stage 1 pressure wound, DTIs are non-blanchable, meaning the skin discoloration does not lighten when pressed. Unlike a stage 1 pressure wound though, a DTI affects deeper layers of tissue under the skin, even though the surface may still look intact.   

Common Causes of Pressure Wounds in Nursing Homes

Bedsores develop due to prolonged pressure on the skin, cutting off circulation and leading to tissue damage. Often times, bedsores most commonly develop on bony areas of the body where there is less cushion from muscle or fat. The most common areas pressure wounds develop are the tailbone (sacrum & coccyx), buttocks, and heels. Other common areas can include hips, back of arms/legs, back of head, shoulder blades/spine, and hips. 

The most common causes of bedsores in nursing home residents include:

• Lack of Repositioning. Failure of nursing home staff to reposition residents regularly leads to prolonged pressure on certain areas of the body.
• Immobility. Residents who are bedridden or wheelchair-bound are at higher risk of skin breakdown. 
• Poor Nutrition and Hydration. Malnutrition and dehydration weaken the skin and slow healing.
• Inadequate Hygiene and Moisture Control. Leaving residents unkempt, without bathing, and in soiled diapers increases the risk of skin breakdown.

How Bedsores Can Be Prevented

Nursing homes can and should take steps to prevent the development of pressure wounds. In fact, federal regulations require nursing homes to do so. Simply put, nursing homes have a duty to implement interventions to prevent pressure wounds, including:

• Frequent Repositioning. Bedridden residents, or residents who need assistance with bed mobility, should be turned and repositioned by nursing home staff. The most common turning and repositioning schedule is every 2 hours. A nursing home resident's care plan or individualized service plan should specify how often the resident will be turned and repositioned by nursing home staff.
• Use of Pressure-Relieving Devices. Special mattresses (like a low air-loss mattress), cushions, padding, and heel boots all can help reduce pressure on vulnerable areas of the body. 
• Proper Nutrition and Hydration. Ensuring residents receive adequate protein, vitamins, and fluids support skin integrity and healing. Nursing home staff should be additionally mindful of those residents who need assistance with feeding or those who are immobile and unable to get food or fluids on their own. 
• Regular Skin Inspections. Skin inspections are crucial to detect early signs of pressure wounds before they worsen. 
• Hygiene and Moisture Control. Keeping skin clean and dry reduces risk of breakdown and infection.
• Staff Training. Nursing home staff must be educated on proper prevention and treatment techniques.   

Wisconsin Nursing Home Neglect Lawyer

Bedsores are not a normal part of living in a nursing home and could be indicative of nursing home neglect. If a loved one develops a severe bedsore due to inadequate care in a Wisconsin nursing home, legal action may be necessary. Nursing homes have a responsibility to prevent and properly treat pressure wounds. If they fail in this duty, they can be held liable for negligence. 

If you suspect that a nursing home's neglect led to a pressure wound, infection, or even death of your loved one, Kristen Lojewski can help. Kristen is an experienced Wisconsin nursing home abuse attorney and can ensure your loved one receives the justice and care they deserve. 

Contact Lojewski Abuse & Injury Law today to Be Seen, Be Heard, Be Safe, and Be Championed.