In this article, Registered Nurse and Nursing Home Administrator, Tiffanie Haemer provides an introduction to pressure ulcers. Her discussion includes the causes of bed sores, common risk factors, steps for treatment and prevention, and some information on how to start your investigation.

Nursing Homes & Pressure Ulcers (Bed Sores) – Expert Article

A pressure ulcer is a lesion caused by unrelieved pressure that results in damage to the underlying tissue. They develop where prolonged pressure against an underlying bony prominence restricts blood flow to compressed tissue. This can occur in less than two hours in a compromised patient. The lack of blood flow ultimately results in tissue necrosis, which can become serious, even fatal, if not properly treated.

Most pressure ulcers are preventable; despite this, the national incidence of pressure ulcers for residents in nursing homes is around 14%. Care providers can prevent bed sores from occurring by identifying at-risk patients and implementing interventions, such as turning and positioning, to mitigate underlying risk factors. For patients who have already developed pressure ulcers, there are well established treatment regimens that, in most cases, can aid in a patient’s recovery.

Illustration of Ulcer Development - image courtesy of High Impact
Illustration of Ulcer Development - image courtesy of High Impact

Common Risk Factors for Pressure Ulcers

Risk Factors are any identifiable condition that increases a resident’s susceptibility to pressure ulcer development. Generally, people who have difficulty moving and are unable to easily change position while seated or in bed are at risk of developing pressure sores, but there are other factors that can exacerbate their risk.

  1. Impaired/ decreased mobility and/or functional ability
  2. Impaired blood flow
  3. Cognitive Impairment
  4. Incontinence of Bowel or Bladder
  5. History of Ulcer
  6. Malnutrition
  7. Decreased fluid intake
  8. Co-morbid conditions, such as Diabetes Mellitus, Coronary disease, renal disease, paralysis.

The presence of risk factors does not ensure the development of pressure ulcers. Risk factors should alert clinicians to the immediacy of need for interventions.

Health Interventions & Facility Requirements

The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate.

The care facility should have a system/procedure to assure:

  1. Assessments are timely and appropriate.
  2. Interventions are implemented, monitored, and revised as appropriate.
  3. Changes in condition are recognized, evaluated, reported to the practitioner, and addressed.
  4. Trends are discussed during the Quality assessment and assurance committee.

Overall a care facility has the responsibility to develop and implement a comprehensive care plan that reflects the needs of each individual in regard to the prevalence of pressure ulcers. The care process should include efforts to identify, stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate.

Common Sites for the Development of Pressure Ulcers

Pressure ulcers develop where there are underlying bony prominences. Prolonged compression of tissue between these bony prominences and the surfaces of beds or chairs can deprive tissues of the blood circulation necessary to maintain good health.

Examples of at risk areas can be found in the diagrams below:

Pressure Ulcer Stages/Categories

Due to the shape of our bones, pressure ulcers typically present in a round shape with the most damage occurring in the center due to the weight distribution of the bone. Pressure ulcers can range from mild reddening of the skin to severe tissue damage—and sometimes infection—that extends into muscle and bone. These sores are grouped by their severity. Stage I is the earliest stage. Stage IV is the worst.

STAGE I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Image Courtesy of NPUAP
Image Courtesy of NPUAP

STAGE II– Partial thickness loss of the dermis presenting as a shallow open ulcer with a red/pink wound bed that does not contain slough (necrotic/avascular tissue in the process of separating from the viable portions of the body).

Image Courtesy of NPUAP
Image Courtesy of NPUAP

STAGE III – Full thickness tissue loss where subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may or may not be present. Stage III Ulcers may include undermining and tunneling.

Image Courtesy of NPUAP
Image Courtesy of NPUAP

STAGE IV– Full thickness tissue loss with exposed bone, tendon, or muscle. Often includes undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface) and tunneling (a passageway of tissue destruction under the skin surface).

Image Courtesy of NPUAP
Image Courtesy of NPUAP

UNSTAGEABLE – Pressure sores are unstageable when the tissue at the base of the ulcer is covered by dead skin that is yellow, tan, green, or brown. In this condition, the actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed.

Image Courtesy of NPUAP
Image Courtesy of NPUAP

SUSPECTED DEEP TISSUE INJURY- Purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear.

Image Courtesy of NPUAP
Image Courtesy of NPUAP

Investigating Pressure Ulcer Incidents:

Whether representing plaintiffs or defendants there are basic documents that a healthcare expert will need to properly review the technical aspects of your case. At a minimum, we suggest having the following records available for expert review:

  • Skin Assessments
  • Treatments
  • Plan of Care

In addition to the documents referenced above, the unique aspects of your case may call for specialized information and evaluation. Our experts are experienced in healthcare and supervised care environments and can help you navigate the industry standards and organizational documents relevant to your case.

Nursing Home & Assisted Living Forensic Investigations

The experts at Robson Forensic are frequently retained to investigate the adequacy of care provided in nursing homes and other assisted-living facilities. Our experts can address many aspects of these cases from administrative policies and procedures, to the level of care provided by healthcare professionals, or the maintenance and custodial practices of care facilities.

For more information, visit our Healthcare Supervision practice page.


Featured Expert

Tiffanie L. Haemer, NHA, RN, WCC, DWC, RAC

Nursing Home Administrator & Healthcare Expert

Tiffanie Haemer is a healthcare expert who is a nationally licensed Nursing Home Administrator, Registered Nurse, Wound Care Specialist, Diabetic Wound Care Specialist, and an expert in Resident Assessment Coordination. Her experience ranges from treating patients as a direct care provider to overseeing operations as a Corporate Compliance Officer, focusing on Federal, State, and Local Regulations. Ms. Haemer applies her expertise to forensic casework involving the standard of care regarding: injuries, abuse, neglect, compliance, and fraud cases. Tiffanie’s experience provides her with a broad perspective and the ability to review and analyze incidents from multiple viewpoints within a case.


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