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Legal Implications of Pressure Injuries/Ulcers: What Clinicians Need to Know

Practice Accelerator
October 31, 2018

"If he has a bedsore, it's generally not the fault of the disease, but of the nursing." Florence Nightingale (1859)

"Has Your Family Member Developed Bedsores While in a Hospital, Nursing Home, or Assisted Living Facility?" This is what you will see attorneys advertising on social media sites and television. The driving message is that your loved ones aren't receiving the quality of care they are owed. This is considered negligence and abuse. The most recent estimations of pressure injuries/ulcers in different health care settings are noted to be 29% in home care, 28% in long-term care, and 15% in acute care.1 Pressure injuries/ulcers are the second most common cause of civil suits alleging medical malpractice.1,2 As health care clinicians, we need to focus more on pressure injuries/ulcers and how they will affect us. If you are delivering quality of care every second of your work day, that is great. However, this doesn't mean that you will not ever be sitting in a courtroom. In 2009, the University of Michigan completed a retrospective study on pressure ulcer litigation. The finding was that roughly 67% of lawsuits regarding pressure injuries/ulcers did not involve a medical error or omission, and yet nursing homes are being fined, and criminal charges are being filed against nurses, physicians, and even nursing home operators.3

Common Mistakes in Pressure Injury/Ulcer Documentation

The following are common mistakes made while documenting pressure injuries/ulcers that might leave a health care clinician open to litigation. Be aware of these errors, so you can avoid them in your own practice.

  1. Off-label drug use
  2. Orders that say for nurse to "mix" – only pharmacists compound
  3. Outdated policies and procedures
  4. Incomplete standing orders
  5. Orders outside scope of practice
  6. Documentation discrepancies (wound type, wound location, incorrect staging)
  7. Failure to implement wound treatment upon finding
  8. Use of doughnut devices, synthetic sheepskin pads, water-fill gloves
  9. Poor-quality photos, or no photo taken
  10. Gap in weekly wound assessment documentation

Nursing Homes are Under the Microscope

We have heard it many times. The classic pressure injury/ulcer lawsuit case: A 91-year-old woman fell in her home and broke her arm. She was later admitted for rehabilitation to a nursing home. She was doing well, then in three months she lost 25 pounds and developed a stage 4 pressure injury/ulcer on her coccyx. She was transported to a hospital, where she died of sepsis. Her family's wrongful death claim alleged the facility was understaffed, making it impossible to provide appropriate care for their patients. Facility records showed nurse hours were below state and industry standards. The jury agreed, awarding a $12 million verdict. Annual nursing home surveys are performed to identify any deficits related to the services provided. These can be in two categories: Actual and Potential. The survey process is normally a few days that involves on-site observations and interviews with staff, physician, family, and patients. Medical record reviews are involved as well.4 The seriousness of the deficiency (F-Tag) is determined by the "Scope and Severity" of the issue. Severities are categorized as a Level 1, 2, 3, or 4. The scope refers to how many residents/patients, and the severity is how serious the issue is or potential for harm. Immediate jeopardy is the most severe F-Tag. Below are some of the F-Tags related to the treatment of pressure injuries/ulcers:



There is an increase in pressure injury/ulcer-related lawsuits in every health care setting. Weekly audits of wound care documentation will help minimize discrepancies. Providers and clinicians must become more proactive in protecting themselves from litigation. Document in a holistic manner versus a checkbox approach. Educate your patients as much as yourself and staff.


1. Petrone K, Mathis L. Pressure ulcer litigation: what is the wound center’s liability? Today’s Wound Clinic. 2017;11(9).…. Accessed on October 8, 2018.

2. Fleck CA. Pressure ulcers. J Legal Nurse Consult. 2012;23(1):4–14.

3. Fife C, Yankowsy K. Legal Implications of Pressure Ulcers. Medline University. eCourse. 2017.

4. Mastrangelo K. Immediate Jeopardy: Scope and Severity. Harmony Healthcare International. 2018.…. Accessed on October 8, 2018.

Suggested Reading

Centers for Medicare and Medicaid Services. CMS Manual System, Pub. 100-07 State Operations Provider Certification, Appendix PP, F-Tag 314 Current Guidance to Surveyors.

Woodlawn, MD : Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services. CMS Manual System, Pub. 100-07 State Operations Provider Certification, Appendix PP for Phase 2, F-Tag Revisions, and Related issues, F-Tag 686 Current Guidance to Surveyors.

Woodlawn, MD: Centers for Medicare and Medicaid Services.

Nightingale F. Notes on Nursing: What It Is, and What It Is Not. New York: D. Appleton and Company; 1860.

Schank JE, Fife CE. Can we talk?: The National Plaintiff's Advisory Panel? Pressure ulcers, litigation and the NPUAP's new staging system. Ostomy Wound Manage. 2018;64(2).…. Accessed October 8, 2018.

Treadwell T. Off-label use of medications and therapies in wound care. Wounds. 2010;22(4):87. 

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.