Legal Implications of Pressure Injuries

Kathleen Martin RN, MSN, MPA, LNHA, CPHQ, WCC, HACP
Pressure Injuries
Legal Implications of Pressure Injuries

Your facility receives a letter from a personal injury attorney who alleges that you, personally, along with your facility were negligent in the care, more specifically, wound care, of a former patient. You are petrified!

Being forewarned with some helpful tips can prevent the likelihood of such an occurrence.

We as nurses are not familiar with the legal system. We have nothing to do with it, if it’s a good day! We go to work with the intention of providing the best care to our patients and don’t often think of being involved in any litigation.

There are several mistaken beliefs that favor the plaintiff in pressure ulcer litigation cases:

  1. All pressure injuries are preventable: various studies have shown that even full-thickness pressure ulcers occur even under excellent care.
  2. Two-hour turning is required to prevent pressure injuries: A randomized controlled trial funded by the NIH (and to date, the only one) showed that even among high-risk patents, every four hours did not increase pressure ulcer formation compared with every two hours. This turning designation was adopted by healthcare facilities as their standard.
  3. Pressure ulcer “prevention” protocols: This term “prevention,” implies that pressure ulcers can always be prevented and when they do occur, it is because the prevention protocol failed to prevent the ulcer(s).

The staging system itself: the most powerful weapon in the arsenal of the plaintiff’s attorney is the current pressure ulcer staging system. The numeric nature of the staging system implies progression through the stages, even though the website of the National Pressure Injury Advisory Panel (NPIAP, formerly the NPUAP) states differently. However, the NPIAP website defines the mechanism of pressure injury as “localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device.” This definition implies an “outside to inside” progression. When juries are told that a wound “progressed,” this implies that if the clinician had done the right thing, the wound would not have “progressed.” The attorney likes to show that a stage II wound progressed to a stage IV.

  1. Failure to update care plans. We may write them, but don’t often update them with accurate information.
  2. Having too many forms and chart locations to document wound care and prevention interventions.


How to reduce your risk of litigation:

While the focus of this piece is to reduce your risk of litigation, it is also to reduce the risk of pressure ulcers in your patients. All wounds are a symptom of disease and pressure injuries are symptomatic of many diseases (e.g. poor nutrition, poor hydration, fragile skin, immobility, muscle weakness, etc.).

Here are some ways that clinicians can reduce the risk of litigation around pressure ulcers:

Document patient and family education around pressure injury prevention (e.g., the importance of nutrition, hydration, skin care, etc.).

  • When pressure injuries occur, record all of the associated patient risk factors and address mitigation strategies for the modifiable risk factors.
  • Describe the precise location of the injury. Terms like “buttock” are imprecise and could represent any area from the sacrum to the ischial spines. Lawsuits have been lost when a severe pressure ulcer on the sacrum was linked to incontinence-associated dermatitis that occurred months before in the gluteal cleft, because both locations were simply described as the “buttocks.”
  • Do not mix up or conflate stages of wounds related to venous ulcers: They are not pressure ulcers. By staging them, you confuse the accurate information, and make a non-pressure ulcer into one.
  • Document when ulcerations heal or close.
  • Document skin and wound status immediately upon admission. Don’t delay. Complete assessment within 8 hours of admission – head to toe – and document. It is critical to discern, upon admission, the existence of a deep tissue pressure injury (DTPI). Look for red and/or purplish/maroon skin coloring, most times, over bony areas. This is due to direct pressure to the skin and soft tissue with resulting ischemia. This type of injury will open to a rather large ulcer in a short amount of time. The obvious open wounds should be assessed upon admission. A day after admission is too late.
  • Describe the lesion (type of tissue) you see. The staging system is confusing and areas that represent different stages can coexist. It is better to describe granulation tissue, slough, etc.
  • Be honest and communicate well with patients and family members. Set expectations and answer questions in non-technical terms.
  • Involve hospital “risk management” departments early.

A recurring theme among family members who file malpractice suits is that they, “simply could not get their questions answered.” A family conference takes much less of the clinician’s time than dealing with a malpractice suit.

Patients may also believe they are owed a monetary settlement for their suffering and that since it will be paid by an insurance company, filing a lawsuit is simply the means to receiving an insurance payment. They may be unaware that clinicians will be formally accused of either negligence or malpractice and even if the case is dismissed, the mere fact the suit was filed will follow a practitioner for the rest of their lives when they obtain or renew hospital privileges or when they join care organizations.

So, avert such a letter coming to your facility and yourself!

Nancy Morgan RN, BSN, MBA, WOCN is an experienced clinician, successful business leader, and accomplished nurse educator in the field of wound management. She is the co-founder of the Wound Care Education Institute, (WCEI®), Wild on Wounds Productions; and, most recently established Nancy Morgan Wound Care offering innovative, educational resources including seminars, webinars, social media and wound care marketing tools to assist and support wound care clinicians at the bedside.  Nancy is one of the most distinguished wound care educators, delivering nearly 1200 lectures, conference keynote addresses, seminars, webinars, and bedside consultations during her career.

Information is courtesy of Nancy Morgan Wound Care, copyright 2022.  

DISCLAIMER:  All clinical & legal information, text and graphics, in this blog are intended to assist with determining appropriate wound therapy or proper legal information.  It is not intended to be a substitute nor constitute providing legal or medical care or advice, diagnosis, or treatment.  Responsibility for final decisions and actions related to legality and care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians  and their legal representation.  Individuals should always contact their healthcare providers for medical or emergency-related care and/or contact their retained attorneys or their legal representation.
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