Pressure ulcers go by many names including pressure sores, bedsores, decubitus ulcers, and pressure injuries. The elderly are at a high risk of developing these potentially life-threatening injuries, and they are a common occurrence in long-term care facilities, nursing homes, and hospitals.
While bedsores can be unavoidable, they may also be a warning sign of nursing home neglect. Nursing home staff have a duty to ensure residents receive proper care to prevent and treat pressure injuries. If your loved one has developed a pressure sore due to negligence, the nursing home may be held accountable.
Causes & Stages of Bedsores
A bedsore or pressure sore happens when pressure on the skin for extended periods of time limits blood flow to the skin. This causes tissue damage as a lack of blood flow causes the skin to die.
There are three primary factors that lead to decubitus ulcers:
- Shearing when two surfaces (such as a bed and the body) move in opposite directions.
- Friction when the skin rubs against bedding or clothing. Fragile skin, especially when moist, is more likely to be injured due to friction.
- Constant pressure. When one part of the body is subjected to constant pressure, it reduces blood flow. This damages tissue and eventually causes tissue death.
Pressure ulcers are most likely to develop on bony areas of the body such as the hips, elbows, shoulder blades, tailbone, and spine. Pressure ulcers are described in stages.
- Stage 1: The wound is not open. The skin has no tears or breaks, but it is reddened and blanches (or briefly loses color) when pressure is applied and released. In patients with darker skin, the damaged area may appear a different color than surrounding skin. The skin is usually warm to the touch and may be painful. The damaged area may feel softer or firmer than surrounding skin.
- Stage 2: The skin has started to form a tear, open wound, or ulcer. It is typically quite painful and tender. The wound may look like a blister, scrape, shallow crater, or, sometimes, like a fluid-filled blister. By stage 2, the skin may already be too damaged to heal in vulnerable people with vascular issues, poor healing, or skin failure.
- Stage 3: The sore has worsened and started to deepen into tissue below the skin. There may be fat visible in the wound which appears like a crater.
- Stage 4: This is a very deep injury that reaches the muscle or bone. Tendons and joints may be affected. Bone or muscle is visible with a stage 4 pressure wound.
By the time a pressure injury reaches stage 3, it may cause little pain due to significant damage to the tissue and nerves. It’s also possible for a pressure ulcer to cause damage to deep tissue without an open wound.
How Quickly Can a Pressure Ulcer Develop?
A pressure ulcer happens when blood supply to the skin is disrupted for two or more hours. These injuries can develop over hours or days, however. In vulnerable people, a pressure sore can develop and reach stage two within hours.
Tips for Bedsore Prevention
While not all bedsores are preventable in very vulnerable people, they are usually avoidable. The following steps can be taken to prevent pressure ulcers in people at risk.
- Frequently change positions. Nursing home residents who are immobile in a bed or wheelchair should have their position changed carefully and frequently. A resident should be repositioned every 30 minutes in a wheelchair and every 1-2 hours in a bed.
- Perform a skin assessment every time care is provided. Note red areas that don’t disappear or new wounds. When caught early, a stage 1 bedsore can be treated and potentially heal in days.
- Use the right mattress, bedding, wheelchair cushion, and other supports based on the resident’s needs. Special shoulder blade and heel pads reduce pressure on the back and feet. A water, air, or gel mattress can be readjusted on a set schedule to change pressure.
- Incontinence care is crucial. Skin care for someone who is incontinent may include the use of absorbent pads, frequent changing of incontinence products, gentle cleansers with a neutral pH, moisturizing, the use of barrier products, and avoiding scrubbing the skin.
- The bed should be elevated to no more than 30 degrees for residents who require elevation. This reduces shearing from sliding down the bed.
Who Is at Risk for Bedsores?
The following are the most common risk factors for developing pressure ulcers.
- Advanced age. Two-thirds of pressure ulcers occur in people 70 and older. Seniors are at an increased risk for many reasons: thinner and more fragile skin, mobility issues, and a higher rate of certain health conditions.
- Immobility. Difficulty moving or changing positions makes it easy for a pressure wound to develop. People who are bound to a wheelchair or bed have a high risk of pressure wounds. The greater the immobility, the higher the risk of a pressure ulcer. People living with paralysis are at a very high risk of pressure injuries. One study found a prevalence of 34% in people with quadriplegia and 47% in people with paraplegia.
- Incontinence. Extended exposure to stool or urine makes skin more vulnerable.
- Loss of sensation. People who have nerve damage or a loss of sensation and cannot feel discomfort or pain are at a higher risk of a pressure injury. These patients do not feel the discomfort that tells them they need to change positions or adjust their position, even if they are able to. Neurological disorders, spinal cord injuries, and diabetes all increase this risk.
- Vascular disease. Conditions that affect blood flow, such as peripheral artery disease (PAD) and diabetic vascular disease make it easier for tissue to become damaged due to pressure.
- Dehydration and malnutrition. Poor hydration and nutrition are necessary to maintain skin and prevent tissue breakdown.
- Obesity. Being overweight increases pressure on the skin, tissue, bones, and blood vessels. Obesity also reduces mobility and may come with comorbidities like diabetes and vascular disease. One study found patients who are obese are twice as likely to develop a pressure ulcer than people who are a normal weight. Another study found the chances of pressure ulcers were up to 19% higher for nursing home residents who were obese compared to non-obese residents.
Bedsores and Malnutrition
One of the most overlooked risk factors of pressure ulcers is poor nutrition. Someone who is dehydrated or malnourished is at an increased risk of developing a pressure injury when they lack nutrients like zinc, iron, and protein necessary to maintain and heal skin.
Malnutrition may contribute to the development of a pressure ulcer. It also reduces the skin’s ability to heal once a sore develops. Poor nutrition can lead to slow or non-healing wounds. Malnutrition may also lead to significant weight loss that increases pressure on bony areas of the body and compromises the immune system.
One study found a strong link between pressure ulcers and malnutrition in elderly patients in long-term care. This study found a statistically significant difference in nutrition between patients with and without pressure ulcers.
It’s estimated that up to 85% of nursing home residents are malnourished. Seniors are at risk of malnourishment due to poor dental health, difficulty swallowing or chewing, and illnesses which may reduce appetite or how the body processes nutrients.
Sadly, it can also be the result of nursing home neglect. Even if a resident has health issues that make proper nutrition challenging, it is the duty of the long-term care facility to develop a nutrition and care plan. A nursing home may take several steps to ensure residents receive proper nutrition such as:
- Appetite stimulants
- Digestive aids
- Soft foods
- Nutrient-dense foods
- Frequent snacks
- Family-style dining
- Personalized nutrition plans overseen by a dietitian
What Causes Bedsores in Nursing Homes?
Pressure injuries are common in nursing homes as residents may have many risk factors including fragile skin, advanced age, limited mobility, incontinence, and comorbidities like diabetes. Most residents are in a nursing home for care for the very issues that make them at risk of a bedsore.
Not all pressure wounds in a nursing home are avoidable, but most are with proper medical care. Pressure ulcers can develop or worsen in long term care when nursing home staff fail to:
- Provide adequate nutrition and hydration
- Reposition residents frequently
- Properly move a resident, such as from a wheelchair to a bed or while repositioning in a bed
- Regularly change the resident’s clothing and bedding
- Use a safe product to absorb moisture and prevent damp bedding
- Ensure residents have comfortable shoes that do not place pressure on the toes and heels
- Perform thorough skin assessments regularly to detect early signs of pressure injuries
Are Bedsores Common in Nursing Homes?
According to the CDC, up to 28% of nursing home residents have decubitus ulcers. In 2004, about 11% of nursing home residents had pressure injuries. About 50% of these pressure ulcers were stage 2. Certain residents are at an increased risk.
- 1 in 5 residents who recently experienced weight loss had a pressure ulcer
- A nursing home resident at the facility for a year or less had a higher risk of a pressure injury than a resident with a longer stay
- Nursing home residents with significant immobility were 11% more likely to have a pressure injury
- Residents who took 8 or more medications had a higher rate of pressure injuries
- Residents with recent incontinence were more likely to have pressure ulcers
Questions to Ask if Your Loved One Has Developed a Pressure Ulcer
If your loved one has developed a pressure ulcer, you may be unsure of what to do to make sure they are getting the care they need. It’s important to advocate for your loved one’s health and safety by asking the facility administrator or nursing director questions such as:
- How severe is the pressure ulcer?
- Is there an infection? Is there a high risk of infection?
- When was the pressure injury first noticed?
- What treatment has been provided?
- What is the treatment plan in place to prevent the wound from worsening?
- How long was the resident left in a wheelchair or bed without repositioning?
- Could the pressure wound have been prevented?
You can also ask to review the standard of care the nursing home staff practiced. Make sure you keep notes on what staff members tell you about your loved one’s condition including dates, times, and staff names.
The next step is determining if you need to take further action. This will depend on the severity of the wound, how well it’s treated, and whether you suspect neglect was the cause.
Are Bedsores a Sign of Neglect?
Not all bedsores are preventable. This is a frequently cited misconception, but pressure ulcers can happen despite strong interventions, preventative measures, and treatment. However, the more advanced a pressure injury becomes, the more likely it could have been avoided. Except in very rare cases, a pressure ulcer should not be allowed to progress to stage 4, for instance, as proper wound care should have been implemented earlier.
The federal government has even made the determination that pressure ulcers in a nursing home should not develop “unless the individual’s clinical condition demonstrates that they were unavoidable” in its quality of care requirements for long-term care facilities.
If your loved one has developed a pressure injury, it is a red flag that they are not receiving the care they deserve. Nursing home staff have a duty to ensure your loved one receives proper hygiene, nutrition, repositioning, medical care, and other care to prevent painful and potentially life-threatening pressure sores.
How do you report nursing home elder abuse or neglect?
If you believe your loved one’s pressure ulcer was the result of negligent care or neglect, it’s important to take action quickly to protect them from further harm.
Your local long-term care ombudsman is a good place to start to report suspected nursing home abuse or neglect. Find your local ombudsman office here.
You can also report suspected neglect to the California Department of Public Health (DPH). You can file a complaint online through California Health Facility Information Database. You should be notified within 48 hours that an investigator has been assigned to your case.
Ombudsmen and Department of Health officials are trained to investigate abuse and neglect to determine how an injury like a pressure sore occurred. They will also have access to your loved one’s medical charts and facility records, and they can interview nursing home staff.
Medical Complications of Bedsores
Bedsores aren’t just painful; they can lead to serious and even life-threatening complications. The following are the most serious complications older adults may face if a bedsore develops and isn’t treated properly.
Infections & pressure ulcers
One of the most common risks of a decubitus ulcer is infection. Damaged tissue can lead to cellulitis, an infection of the skin and soft tissue. This infection can be painful and lead to redness, swelling, and warmth of the infected skin.
A more serious complication can occur when the infection goes deep into the bones and joints. A joint infection, or septic arthritis, damages tissue and cartilage in the joint. When the infection spreads to the bone, it is called osteomyelitis. These infections can be painful, limit function, and lead to disability and worsening health.
Can bedsores cause sepsis?
Sepsis is a life-threatening reaction of the body to infection. It happens when the immune system releases chemicals to fight infection, triggering widespread inflammation and damage to organs and tissue.
Sepsis can be caused by any type of infection almost anywhere in the body. Most infections that lead to sepsis start on the skin or in the urinary tract, lung, or gastrointestinal tract. Bacteria is responsible for most causes of sepsis, particularly septicemia, or a bacterial infection of the blood.
Wounds are a leading cause of sepsis.
Seniors account for 65% of all cases of sepsis and those with existing medical issues like an open wound or diabetes are at an even greater risk. Nursing home residents are 6x more likely to visit an ER for sepsis than non-residents.
Sepsis has a high risk of fatality among vulnerable people. It can also lead to organ dysfunction, amputation, and a higher risk of another infection. Every year, more than 20,000 elderly adults develop moderate to severe cognitive impairment caused by sepsis alone.
Bedsores can lead to sepsis when they become infected. Cellulitis, osteomyelitis (bone infection), septic arthritis (joint infection), and localized skin infections can all lead to sepsis.
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Can you die from a pressure sore?
Bedsores are believed to cause 60,000 deaths every year according to the Agency for Healthcare Research and Quality. One study found pressure ulcers listed as a cause of death for more than 114,000 people between 1990 and 2001. About 80% of deaths associated with bedsores happened in people 75 and older.
In vulnerable elderly residents, damaged skin from a pressure sore can quickly become life-threatening when bacteria enters and spreads. This can lead to sepsis, organ failure, and death.
Negligent care that allows a pressure ulcer to develop, or inadequate treatment of a bedsore, is a form of nursing home abuse. If your loved one died as the result of an infection or bedsore caused by nursing home neglect, the nursing home may be held accountable through a wrongful death action.
Has your loved one developed a pressure ulcer in a nursing home? This is a major sign that your loved one has been the victim of nursing home neglect. After addressing your loved one’s immediate medical needs and contacting your local ombudsman and/or the DPH, the next step is contacting a California nursing home abuse lawyer.
Berman & Riedel, LLP can help you investigate your suspicions, represent your loved one, and help them recover financial damages for the pain they have suffered. Our law firm specializes in elder abuse and neglect cases with results that speak for themselves. Contact our law office today at (858) 252-3143 or fill out the contact form to schedule a free consultation to discuss how we can help you and your loved one.