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Legal Perils and Pitfalls of Wound Care – Extrinsic Risk Factors for Unavoidable Pressure Ulcers

"At all times material hereto, defendant failed to develop an adequate care plan and properly monitor and supervise the care and treatment in order to prevent her from suffering the development and deterioration of bed sores."

The BEST legal defense in a pressure ulcer lawsuit is if the facility and legal counsel can effectively show that the pressure ulcer was unavoidable. Unavoidable pressure ulcers occur when a patient develops one even though the facility meets standards of care related to pressure ulcer prevention and treatment. These include assessments and interventions such as risk assessment, nutrition, support surfaces, regular wound assessments, wound treatments, mobilization, turning and positioning, and physician and family notification. And don't forget that in a pressure ulcer lawsuit, a pain and suffering allegation is almost assuredly a part of the complaint, so the presence of pain and subsequent interventions need to be addressed as well!

Intrinsic Versus Extrinsic Risk Factors for Pressure Ulcer Development

Intrinsic factors related to pressure ulcer development consist of "the patient's comorbidities and physiologic conditions impacting wound healing."1 In my last blog, I discussed intrinsic risk factors, using predominantly the National Pressure Ulcer Advisory Panel's (NPUAP) consensus panel article of 2014.2 This list was quite lengthy and included tissue oxygenation, age, end of life, infection and immunosuppression, body habitus, and multiple other underlying chronic conditions. Extrinsic risk factors include "external or environmental sources that disrupt the wound healing process."1 That is the subject of this blog, and I will once again use the NPUAP article as a guide.

Extrinsic Risk Factors for Pressure Ulcer Development

  • Head of bed (HOB) elevation. Elevating the HOB 30 to 40 degrees is a recommendation to prevent aspiration and ventilator-acquired pneumonia. Patients who have tube feedings are particularly at risk. This directly contradicts all pressure ulcer recommendations because HOB elevations significantly increase shear and interface pressures, despite all turning practices. Ideally all patients with HOB elevations should be put on higher level surfaces sooner rather than later to address the increased pressures that result, and document the reason for the HOB. Having a doctor's order in place strengthens the case.
  • Hip fracture. Hip fractures are associated with significantly increased morbidity and mortality and an increased risk of PU development by virtue of long periods of immobility. Patients with hip fractures generally are frail older adults with multiple comorbidities.
  • Prone positioning. Pressure ulcer incidence rates as high as 65% have been reported among patients in a prone position.3
  • Nutrition. Malnutrition is a well-known risk factor for pressure ulcer development and is a frequent focus of pressure ulcer lawsuits. Protein-energy malnutrition (lack of protein and calories) causes the body to break down muscle tissue for energy (defined as maintenance of normal body functions), resulting in sarcopenia (loss of lean body mass). Unintended weight loss is a common indicator of malnutrition. Keeping track of weight loss is a critical intervention and something that attorneys closely scrutinize, as well as what other nutritional interventions and supplements have been implemented.
  • Hospital length of stay (LOS). Several studies are listed in the NPUAP article citing the relationship between hospital LOS and adverse events such as PU development. One study found that 97% of all pressure ulcers occurred among study participants whose LOS was greater than seven days.4 It makes sense, doesn't it? The sicker they are, the longer they are in the hospital, the more they are at risk!
  • Smoking. The nicotine in cigarettes causes vasoconstriction and tissue ischemia, not to mention the deleterious effect of carbon monoxide, which displaces oxygen from hemoglobin. Multiple studies as well as plain old common sense tell you that cigarette smoking is a huge risk factor for pressure ulcer development, and attorneys have successfully used a smoking history to prove contributory negligence.
  • Medical devices. Often very necessary and lifesaving, medical devices nevertheless are responsible for between 20% and 40% of all new pressure ulcers. These include continuous positive airway pressure devices, urinary catheters, restraints, cervical collars, nasogastric tubes, nasal cannula oxygen tubing, and external fixators. Or how about when that leg cast comes off and everyone has been wondering what the smell was? Oh my, a stage 4 pressure ulcer!
  • Non-adherence. Patient rights dictate that patients have the right to make informed decisions and refuse treatment, which can impact cooperation with pressure ulcer prevention and treatment measures. Refusals can result in an unavoidable pressure ulcer. Staff should always try to ascertain the reason for non-adherence and document this. Attorneys look to see whether the patient was informed of and educated about the consequence of non-adherence and whether this took place on a regular and consistent basis. Just as with smoking, contributory negligence may become a factor in the lawsuit, thereby reducing the facility's liability.


Pressure ulcer development is multifactorial and complex. Ultimately, whether the cause is extrinsic or intrinsic, good documentation of assessments and risk factors is a necessary component of limiting liability in a lawsuit.


1. Netsch D. Refractory wounds: assessment and management. In Doughty D, McNichol L (Eds.), Wound, Ostomy and Continence Nurses Society Core Curriculum Wound Management. Philadelphia: Wolters Kluwer; 2016:183.

2. Edsburg LE, Langemo D, Baharestani MM, Posthauer ME, Goldberg M. Unavoidable pressure injury; state of the science and consensus outcomes. J Wound Ostomy Continence Nurs. 2014;41(4):313–34.

3. Bajwa AA, Arasi L, Canabel JM, Dramer DJ. Automated prone positioning and axial rotation in critically ill, non-trauma patient with acute respiratory distress syndrome (ARDS). J Int Care Med . 2010;25(2):121–25.

4. Eachempati SR, Hydo LJ, Barie PS. Factors influencing the development of decubitus ulcers in critically ill surgical patients. Crit Care Med. 2001;27(10):1599–605.

About the Author

Heidi H. Cross, MSN, RN, FNP-BC, CWON, is a certified Wound and Ostomy Nurse in Syracuse, NY. She has extensive experience caring for wound and ostomy patients in acute care as well as in long term care facilities. Currently, she is employed by CNY Surgical Physicians consulting for nursing homes in the Syracuse area, and has served as an expert witness for plaintiff and defense attorneys.

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.