Skip to main content

Legal Perils and Pitfalls of Wound Care: Risk Factors for Unavoidable Ulcers

Part 6 in a multi-part series looking at the basics of avoiding litigation as a health care provider. Read Part 1 Here, Part 2 Here, Part 3 Here, Part 4 Here, and Part 5 Here.

According to the Agency for Healthcare Research and Quality,1 more than 17,000 lawsuits related to pressure ulcers are filed annually in the United States, second only to wrongful death lawsuits. One of the greatest gifts to defense attorneys was when the Centers for Medicare & Medicaid Services (CMS) published F-Tag 314, finally acknowledging that some ulcers can occur despite best care. The facility essentially can maintain, "Hey, we did everything we were supposed to, and despite that, the patient developed that pressure ulcer"—that is, the ulcer was unavoidable. To prove unavoidability, proper documentation (proof) of best care needs to be in place, as well as documentation that all proper prevention and treatment measures were implemented.

Top of My Unavoidable List: Skin Failure

Intrinsic risk factors include skin failure, which often (but not always) is associated with end of life. Skin failure has been defined as "an event in which the skin and underlying tissues die due to hypoperfusion that occurs with severe dysfunction or failure of one or more organ systems."2 As we know, skin is an organ just like the heart, kidney, and liver, and it is the largest organ of the body. Unless there is actual medical malpractice, how often do we hear about patients suing cardiologists for heart failure, nephrologists for kidney failure, and hepatologists for liver failure? Granted, we have serum laboratory values for failures of the heart (B-type [or brain] natriuretic peptide), kidney (blood urea nitrogen, serum creatinine), and liver (liver enzymes); however, none exist for skin failure.

But why so many lawsuits for pressure ulcers, when organ failure (as in other organs) may be the causative issue? Why do families and patients get upset enough with pressure ulcers that they feel compelled to sue? In addition to being the largest organ, skin is outwardly visible, and skin breakdown can be shocking and jolting to patient family members, unlike the invisibility of many other organs. It can easily be interpreted as a sign of abuse and neglect and has become the low hanging fruit of lawsuits and the bread and butter of many medical malpractice plaintiff attorneys. Just look at some of the ads.

What Does the National Pressure Advisory Panel Have to Say?

Many experts and expert bodies have weighed in on this issue, and some of these were detailed in my last blog. I would like to focus on the consensus panel article of the National Pressure Ulcer Advisory Panel (NPUAP), published in 2014.3 This article divides the risk factors into intrinsic and extrinsic factors. Please see this article for a more complete version. I will discuss extrinsic risk factors in the next blog.

Intrinsic factors:

  1. Impaired tissue oxygenation or cardiopulmonary dysfunction. This category applies particularly to patients in the intensive care unit and includes vasopressor use (blood is being shunted from the periphery, i.e., skin and underlying tissues, to core organs), hypotension, hypoxemia, anemia, hypoventilation, and congestive heart failure.
  2. Hypovolemia, defined as an inadequate volume of blood in the circulatory system, thus compromising tissue perfusion in the periphery and vital organs.
  3. Infection, sepsis, and hypoalbuminemia. Invasion and multiplication of microorganisms cause cellular injury, releasing toxins and competing with normal metabolism of the body. Inflammation results, with low albumin levels. Shock leads to inadequate tissue perfusion.
  4. Body edema and anasarca, leading to compromised tissue perfusion and fragility and a decreased tolerance to pressure and shear.
  5. Lower extremity arterial and venous disease, including venous insufficiency and neuropathic disease. Unless the underlying factors are corrected, deterioration may be the only expectation.
  6. Chronic kidney disease. Changes in tissue tolerance as a result of renal disease, as well as mobility limitations and long times spent in a sitting position during dialysis, may increase the likelihood of pressure ulcer development.
  7. Hepatic dysfunction, which results in hypoalbuminemia, edema and anasarca, ascites, cerebral dysfunction, and coagulopathies.
  8. Other factors: sensory impairment, multiple sclerosis, stroke, coma, spinal cord injury (30% to 50% of all patients with spinal cord injury develop a pressure ulcer during the first month after injury4).
  9. Anesthesia and operating room time. Anesthesia causes circulatory issues that increase risk for pressure ulcers and, of course, alters sensory ability to feel discomfort.
  10. Age. Risk for pressure ulceration occurs at both ends of life. Neonates, particularly preemies, lack proper skin structures to avoid pressure ulcers. In older adults, multiple changes occur in not only the skin but also the underlying tissues, thus increasing risk; 70% of pressure ulcers occur in those 70 years and up.3
  11. End of life and end-stage dementia, leading to poor appetite and nutritional compromise, bedridden status, impaired language and communication, and risk for contractures.
  12. Body habitus. Obesity increases the risk for moisture, shear, friction, immobility, and skin tissue compromise.


Not all pressure ulcers are avoidable, despite best care practices. Contributors to unavoidability include intrinsic risk factors, skin failure among them. Next blog? Extrinsic risk factors for unavoidable ulcers according to the NPUAP.


1. Agency for Healthcare Research and Quality. Accessed April 6, 2019.

2. Langemo D, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19(4):206–11.

3. 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.

4. Consortium for Spinal Cord Medicine. Early acute management in adults with spinal cord injury. A clinical practice guideline for health care professionals. J Spinal Cord Med. 2008;31:408–79.

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.