Pressure Injuries in Elder Abuse Litigation
Pressure injuries — commonly known as bedsores, pressure sores, or decubitus ulcers—make up a significant portion of elder abuse lawsuits in California.
A pressure injury occurs when sustained, unrelieved pressure restricts blood flow, damaging the skin and underlying tissue. Pressure injuries are defined by The Centers for Medicare & Medicaid Services (CMS) as a “localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The… injury can present as intact skin or an open ulcer and may be painful.”
(The term pressure injury is generally favored over the alternatives listed above. The word “pressure” clearly identifies the mechanism of harm, while “injury” implies that the harm resulted from external causes, such as neglect. By contrast, terms like “ulcer” may minimize the sense of culpability.)
A typical scenario involves a nursing home resident developing a pressure injury due to a failure to provide essential bedside care, such as repositioning at regular intervals. Any elder abuse attorney must have a strong working knowledge of pressure injuries and their implications. If you have a loved one in a nursing home, it’s important to have some understanding of the signs and symptoms so that you can remain alert to the risks.
One of the most critical elements of a pressure injury case is photographic evidence. Families may capture images of the wounds, or subsequent healthcare providers may document them as part of medical records. These photos are invaluable in elder abuse litigation in two ways: (1) they help establish how an injury progressed over time, and (2) they strongly influence how juries perceive the severity of neglect. Securing and preserving photographic evidence should therefore be a top priority.
Staging of Pressure Injuries
Pressure injuries are staged based on their severity and progression. To understand staging, it helps to recall the layers of normal skin and tissue:
- Epidermis (outer skin)
- Dermis (deeper skin layer)
- Adipose tissue (fat)
- Muscle
- Bone
Stage 1: Redness of Intact Skin
- Skin is intact but shows localized redness that does not turn white when pressed. The area may feel painful, firm, soft, warm, or cool compared to surrounding tissue.
- No open wound; early indicator of skin stress.
Stage 2: Partial-Thickness Skin Loss with Exposed Dermis
- Shallow open ulcer with a red-pink wound bed, without dead tissue (slough). May also appear as a blister.
- Damage extends through the epidermis but not into deeper tissues.
Stage 3: Full-Thickness Skin Loss
- Tissue loss extends through the dermis into subcutaneous fat, though bone, tendon, and muscle are not exposed. Slough may be present, along with undermining or tunneling.
- Deeper involvement than Stage 2 but still above muscle and bone.
Stage 4: Full-Thickness Skin and Tissue Loss
- Bone, tendon, or muscle are exposed. Dead tissue may be present, with undermining and tunneling.
- High risk of infection, including sepsis.
Unstageable Pressure Injury
Full-thickness tissue loss obscured by slough or eschar. True depth cannot be determined until debris is removed, usually revealing Stage 3 or 4.
Deep Tissue Pressure Injury
- Skin may be intact or broken, with persistent deep red, maroon, or purple discoloration, sometimes presenting as a blood-filled blister.
- Caused by prolonged pressure and shear at the bone-muscle interface.
In next week’s blog, we’ll look at risk factors for pressure injuries in nursing homes and other care settings. If your loved one facility has suffered a pressure injury in a nursing home, a dedicated elder neglect attorney can help you determine whether you have a case. Contact Dudensing Law to talk to an elder abuse attorney in Los Angeles, San Francisco, or Sacramento.
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