A pressure injury case often turns on one question: could this wound have been prevented? The answer usually sits in the chart.
Here is how a nursing expert works through a pressure injury case in a hospital, especially the ICU, or a nursing home, plus the records to request and which expert fits.
Why These Cases Matter
CMS lists Stage III and IV pressure ulcers among its hospital-acquired conditions. When one of these conditions was not present on admission, the hospital is generally not paid the higher rate for it as a secondary diagnosis.
Nursing homes have their own standard. Under 42 CFR 483.25(b)(1), a facility must make sure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop them "unless the individual's clinical condition demonstrates that they were unavoidable."
That word, unavoidable, is where many cases are argued.
Risk Assessment: The Starting Point
Most reviews begin with the risk score. The Braden Scale is one of two widely used adult risk tools named in the AHRQ pressure ulcer prevention toolkit.
An expert checks three things:
- Was risk assessed on admission?
- How often was it repeated? AHRQ notes that in settings where a patient can change quickly, such as critical care, risk assessment should be done more often, such as every shift.
- Did the score lead to action?
AHRQ points out that a "not at risk" total can still hide risky subscale scores, like moisture or friction and shear, that the care plan should address.
Skin Checks and Turning Records
Next comes the skin itself. AHRQ describes a comprehensive skin assessment on admission to the unit, daily, and on transfer or discharge, and in some settings every shift. It also calls for looking under devices such as oxygen tubing.
The expert then compares turning entries with the facility's policy and the care plan:
- Are there long stretches with no turn documented?
- Was the patient too unstable to turn, and was that charted with a reason?
- Were heels offloaded?
- Was skin charted as intact on every shift right up to the day a deep wound was found?
Sometimes the hospital stay itself creates risk that standard Braden interventions cannot fully address. Examples include a long surgery or procedure, prone positioning, ECMO or other cannulas that limit movement, hemodynamic instability where turning drops the blood pressure, or a spine or pelvic injury that restricts repositioning. In those cases the expert looks for:
- Was the specific barrier documented, with the clinical reason and who decided?
- Were alternatives used, such as small position shifts, pressure redistribution surfaces, heel offloading, or padding under devices?
- Was the patient turned or reassessed as soon as it was safe?
- Was the higher risk communicated to the provider and the family, and added to the care plan?
A documented, reasoned limitation with alternatives tried reads very differently from a simple absence of turning entries.
Support Surfaces, Nutrition and Consults
The expert also checks whether the patient was placed on an appropriate support surface, and when. Bed or rental logs can show the actual date a specialty surface arrived, which may differ from the date it was ordered.
Then nutrition: a dietitian consult, intake, weights and labs. And the wound care consult: was one ordered once risk was high or a wound appeared, and how fast?
Staging: Getting the Wound Right
The National Pressure Injury Advisory Panel (NPIAP staging definitions) describes:
- Stage 1: non-blanchable redness of intact skin
- Stage 2: partial-thickness skin loss with exposed dermis
- Stage 3: full-thickness skin loss, fat may be visible
- Stage 4: full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone
- Unstageable: full-thickness loss hidden by slough or eschar
- Deep tissue pressure injury: persistent deep red, maroon or purple discoloration that may evolve quickly
NPIAP also defines a medical device related pressure injury, which usually matches the shape of the device. In the ICU, think endotracheal tubes, masks, cervical collars and lines.
NPIAP notes that Stage 2 should not be used for moisture damage, skin tears or adhesive injuries. A deep tissue injury that later opens can look like sudden decline, when it may reflect damage that started days earlier.
Photos and measurements build the timeline. The expert compares length, width, depth, tunneling, wound bed and drainage across dates. Missing photos, measurements that do not change for weeks, or a sudden jump in size all raise questions.
Avoidable or Unavoidable
Defense experts often point to critical illness: low blood pressure, poor perfusion, sedation or a patient too unstable to turn. AHRQ notes these raise risk in critical care.
Plaintiff experts often ask whether the prevention steps were actually done and charted. A strong unavoidable argument usually needs both a sick patient and a documented prevention plan that was carried out.
Records to Request
- Nursing flowsheets: skin checks, risk scores, turning
- Care plans and updates
- Wound care notes and dated photos
- Support surface orders and bed logs
- Dietitian notes, weights and labs
- Provider orders and progress notes
- Staffing and assignments for key dates
- Skin care and repositioning policies in effect at the time
- For nursing homes: MDS assessments
Share all records through secure, HIPAA-compliant channels.
Which Expert Fits
Match the expert to the question:
- Bedside RN from the same setting (ICU nurse for an ICU case, long-term care nurse for a nursing home case) for the nursing standard of care.
- Certified wound care nurse, such as a CWOCN or WOC nurse, for staging, wound progression and treatment.
- Physician for causation, such as whether the illness, perfusion or other conditions made the wound unavoidable.
Many cases need more than one.
This article is for general educational purposes only and is not legal advice. Laws and regulations vary by jurisdiction and change over time. Consult qualified legal counsel about your specific case.
Looking for an expert? Visit ClinicianExperts.com