When Bedsores Betray: How Hospital‑Acquired Pressure Injuries Reflect Negligence, and What True Prevention Looks Like
- EvaluCare
- May 28
- 7 min read
Updated: May 29
Hospital‑acquired pressure injuries (HAPIs), formerly known as pressure ulcers or bedsores, are not only painful and debilitating but also when they occur under inpatient care, powerful indicators of systemic failure. These injuries, resulting from unrelieved pressure on vulnerable skin, can progress rapidly from superficial reddening to deep, sometimes fatal wounds.
Each year in the United States, an estimated 2.5 million patients develop pressure injuries during a hospital stay, with treatment costs totaling over $11 billion . When HAPIs occur, the question for families isn’t just “What went wrong?” but “Why wasn’t this preventable harm stopped at its earliest sign?”
Pressure injuries of stage 3 or 4, those extending into fat, muscle, or bone, carry a mortality rate exceeding 60% at one year. Not to be misleading in this statistic, is the fact that confounding factors such as the age, health and conditions of patients who develop these types of injuries during care is generally poor.
In this blog, we will explore:
The major contributing factors to HAPI development in hospitalized patients
Evidence‑based prevention measures that every hospital should embed in care protocols—and how each must be meticulously documented
The stark reality that, when HAPIs occur, they almost always signal negligent care
Landmark malpractice cases involving pressure injuries and their financial and human costs
How EvaluCare’s team of quality and clinical experts reviews care processes to pinpoint where prevention may have failed and helps families pursue justice through direct settlement negotiation or referral to a qualified medical malpractice attorney.
In understanding both the science of prevention and the art of accountability, we honor the principle that no patient should leave a hospital with a pressure injury they did not have on admission.
Why Hospital‑Acquired Pressure Injuries Are Never Acceptable
Pressure injuries develop when sustained pressure, often at bony prominences (heels, sacrum, elbows), impairs blood flow, leading to tissue ischemia and necrosis. In healthy, mobile individuals, frequent repositioning and tissue resilience prevent injury. In hospitalized patients—often elderly, frail, sedated, or with mobility impairments—the responsibility for prevention rests squarely with the care team.
The Agency for Healthcare Research and Quality (AHRQ) identifies HAPIs as a hospital‑acquired condition (HAC) that is typically never reimbursed by Medicare when it develops after admission .
Moreover, the National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) categorize these injuries as “never events,” signaling that they reflect care that fell below accepted standards.
Contributing Factors to Negligent HAPI Development
Inadequate Risk Assessment
Failure to use validated tools like the Braden Scale or Norton Scale on admission and regularly thereafter.
Missed high‑risk indicators: incontinence, poor nutrition, altered sensation, or comorbidities such as diabetes.
Poor Repositioning Practices
Repositioning intervals exceeding two hours, despite guidelines recommending turns every 1–2 hours for high‑risk patients.
Lack of lift or positioning devices leading to shear and friction injuries when staff attempt manual turns.
Insufficient Skin Assessments and Monitoring
Failure to conduct head‑to‑toe skin inspections at each shift change by two qualified clinicians (“four‑eyes assessment”).
Missing early signs—blanchable erythema—allowing progression from stage 1 to stage 3/4.
Device‑Related Pressure Injuries
Unpadded medical devices (oxygen tubing, catheters, splints) exerting prolonged pressure.
Poor device securement causing micro‑movements and friction.
Lack of Nutrition and Hydration Support
Inadequate calories or protein to support tissue repair.
Failure to involve dietitians in care planning for at‑risk patients.
Staffing Shortages and Turnover
Understaffed shifts where repositioning and skin checks are deprioritized under time pressure.
Frequent use of agency or travel nurses unfamiliar with unit‑specific HAPI protocols.
Documentation Gaps
Absent or superficial documentation of repositioning, skin assessments, and micronutrient intake.
Irregular or illegible notes impeding continuity of care across shifts and disciplines.
When any of these factors persist, the hospital setting transforms from a place of healing to one of hidden harm. HAPIs that appear on day 5 or day 10 of hospitalization almost invariably reflect breakdowns in risk assessment, prevention effort, or both.
Core Components of a Robust HAPI Prevention Program
Preventing HAPIs demands a multifaceted program that integrates equipment, protocols, and people:
1. Risk Assessment and Stratification
Braden Scale on Admission, every 48 hours, and whenever a patient’s condition changes.
Automated alerts in the electronic health record (EHR) to flag scores ≤16 (moderate to high risk).
2. Repositioning and Offloading
Repositioning schedules posted at each bedside, with two‑person lift protocols for safety.
High‑pressure redistribution mattresses for at‑risk patients.
Heel off‑loading boots and pillows to keep heels elevated and relieve sacral pressure.
3. Skin Surveillance and Documentation
Four‑eyes skin inspections by a nurse and nursing assistant at each shift—documented with body maps and photographs for baseline.
Standardized skin assessment flowsheets within the EHR, capturing stage, wound size, and exudate characteristics.
4. Nutrition and Moisture Management
Early dietitian consult for patients with low albumin, weight loss, or poor oral intake.
Moisture‑management protocols for incontinence: scheduled toileting, moisture‑wicking briefs, and barrier creams.
5. Device‑Related Injury Prevention
Cushioning interfaces under tubing, catheters, and splints.
Scheduled device repositioning every 2 hours, with documentation.
6. Education and Culture
Annual competency training on HAPI prevention for all nursing staff and relevant clinicians.
Unit huddles to review any new HAPIs and reinforce best practices.
Patient and Family Education materials on turning schedules and skin care, empowering engagement.
7. Monitoring and Feedback
Dashboard reporting of HAPI incidence rates by unit and month.
Root cause analysis (RCA) for every stage 3 or 4 HAPI, with action plans tracked to closure.
When these elements function in concert, and are rigorously documented, they create a nearly impenetrable shield against pressure injuries. Conversely, when documentation is absent or perfunctory, it reveals that prevention measures likely were too.
HAPI Documentation: The Negligence Red Flag
In medical malpractice litigation, the absence of documentation is often as damning as documentation of overt lapses. But there is more to uncover than missing documentation. It is overall quality programming. Critical records include:
Braden scores with corresponding risk categories
Repositioning logs, signed by caregivers
Skin inspection notes with body map diagrams or photographs
Nutrition consult notes detailing calorie/protein plans
Device‑offloading orders (e.g., heel boot prescriptions) and compliance confirmation
When chart review reveals blank repositioning logs, no Braden reassessments, or missing skin inspections, it can be infer that care was not delivered at all. In this way, documentation is both preventive medicine and legal protection.
The Legal Landscape: When Pressure Injury Leads to Malpractice Claims
Pressure injury litigation is prolific—the second most common cause of medical malpractice suits after wrongful death proliability.com. According to Proliability, the average settlement exceeds $250,000, with individual awards topping $312 million in the most egregious cases proliability.com. Plaintiffs prevail in up to 87% of these suits.
Notable Cases:
Rosenblatt v. Center for Nursing & Rehabilitation (2021)A long‑term care patient developed a stage 4 sacral ulcer that expanded despite documented nursing care plans. The jury awarded $3 million, finding that the facility violated state law requiring “all care reasonably necessary to prevent and limit” pressure injuries Justia Law.
Christus St. Vincent Regional Medical Center (2011)A 69‑year‑old male patient acquired multiple stage 3/4 ulcers during a prolonged hospital stay. The jury’s verdict of $10.3 million underscored the hospital’s failure to implement routine turning schedules and off‑loading interventions Fierce Healthcare.
Recent Stage 4 Settlement (2025)A patient who was immobile post‑stroke developed a necrotic heel ulcer due to missed repositioning and no pressure‑relief devices. The case settled confidentially for over $1 million, reflecting the high litigation risk associated with preventable HAPIs.
Each of these cases illustrates that, where evidence shows protocols existed but were not followed, courts view pressure injuries as per se negligent—no expert causation defenses can overcome the absence of basic preventive measures.
Compassionate Redress: EvaluCare’s Review and Support
For patients and families traumatized by a preventable pressure injury, the path forward can feel overwhelming. EvaluCare’s multidisciplinary team, comprising quality and medical experts that have managed hospital acquired pressure injury prevention programs can help.
Comprehensive Medical Record Review
Identify gaps in risk assessments, repositioning records, skin checks, and nutrition plans.
Correlate missing documentation with timing and progression of the injury.
Root Cause and Causation Analysis
Determine which element(s) of prevention protocol failed, be it staffing shortages, training lapses, or policy omissions.
Tie identified failures to the patient’s harm, creating an objective linkage for families or their attorneys.
Expert Reporting
Deliver clear, jargon‑free findings that support direct settlement negotiation or formal litigation.
Offer balanced recommendations on reasonable compensation given the injury’s severity and prognostic impact.
Advocacy and Guidance
Work with families to help them understand their rights and options—whether through patient advocacy channels, regulatory complaints, or malpractice claims.
Refer to specialized legal counsel when formal action is required.
At every step, EvaluCare combines healthcare quality and clinical rigor with compassionate support, ensuring that families not only secure accountability but also drive improvements that prevent similar harm to others.
Conclusion: From Harm to Healing
Hospital‑acquired pressure injuries are sentinel events—never acceptable under any modern standard of care. When they occur, the causative chain invariably includes lapses in risk assessment, preventive interventions, and documentation. For patients and families, each bedsore is not merely a wound but a breach of trust, a reminder that the healthcare system failed its most fundamental duty.
Yet every HAPI also presents an opportunity: an opportunity to shine a light on systemic gaps, to hold providers and healthcare organizations across the system of care, from acute care to nursing homes, accountable to implement stronger safeguards that protect future patients.
By rigorously applying evidence‑based prevention measures, heel boots, device off‑loading, four‑eyes skin assessments, nutrition support, and by meticulously documenting every step, hospitals can make HAPIs truly “never events.”
When prevention fails, EvaluCare stands ready to review, analyze, and advocate—transforming personal tragedy into collective learning and supporting families in their pursuit of justice and healing.
For more information on how EvaluCare can review your care for Medical Malpractice, visit EvaluCare Medical Care Review Services.
Learn more at www.EvaluCare.net or email info@EvaluCare.net
References
Padula WV, Delarmente BA. The National Cost of Hospital‑Acquired Pressure Injuries in the United States. Adv Wound Care. 2019;8(2):39–45.
Moore ZEH, Cowman S. Pressure ulcer prevalence and prevention practices in care of the older person in the Republic of Ireland, Northern Ireland, and England: a pilot study. J Clin Nurs. 2012;21(3‑4):173–182.
Proliability. “Pressure Injury Litigation: A Growing Trend.” 2021. proliability.com
National Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. 2019.
The Joint Commission. National Patient Safety Goals. “Reduce the likelihood of patient harm resulting from falls.” 2024.
Institute for Healthcare Improvement. “How‑to Guide: Prevent Pressure Ulcers.” 2017.
For expert review of your medical care records, root cause analysis, and compassionate guidance through settlement or litigation, visit EvaluCare’s Medical Care Review Services: https://www.evalucare.net/medical-care-review-services
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