Risk Management Tools & Resources


Case Study: Patient’s Health Deteriorates in the Absence of Proper Pressure Injury Care


Case Details

The patient was a male in his mid-eighties who had a history of prostate and bladder cancer leading to bone metastasis. Following a hospital stay, he was transferred to a long-term care/rehabilitation (LTC/rehab) facility. When the patient arrived at the facility, the admissions nurse documented that he had a Stage 4 sacral pressure injury.

The patient subsequently developed several other Stage 2 and Stage 3 pressure injuries on the buttocks. Daily skin assessments were not completed, and facility nurses never documented any wound assessment or patient response to wound treatment. Within 2 weeks, the patient developed a C. difficile infection, and the sacral pressure injury progressed to involve the patient’s bone.

Wound VAC therapy was ordered, but didn’t occur immediately. The patient eventually was admitted to the hospital, and his condition continued to worsen. He developed sepsis and pneumonia, and ultimately did not survive.


The major risk management issues in this case revolved around the failure of staff at the LTC/rehab facility to follow proper care protocols and to adequately monitor the patient and document care.

The patient’s Stage 4 pressure injury was documented at admission; 1 day after his admission, a nurse documented redness in the patient’s groin area. However, after that, no further information was documented related to the groin or perineal area.

Additionally, the nursing staff failed to follow the facility’s protocol for daily skin assessments. Although staff did document wound treatment and dressing changes, they did not document wound assessment or response to treatment. Documentation does show that one of the patient’s pressure injuries healed, but the sacral pressure injury continued to deteriorate while the patient was at the facility, and other wounds developed as well.

About 4 weeks after the patient was admitted to the LTC/rehab facility, and after he developed the C. difficile infection, an attending physician ordered wound VAC therapy. The therapy was not started until a week later, but documentation was insufficient to show why the delay in treatment occurred. During the patient’s wound VAC treatment, no follow-up assessments were done, which was in direct conflict with the facility’s policy of weekly wound evaluations. Further, excoriated skin in the groin/perineal region was not addressed in the patient’s care plan.

Following the patient’s death, his family filed a malpractice suit against the LTC/rehab facility citing failure to monitor the patient’s physiological status. The case was settled with a payment made on behalf of the facility.


Pressure injuries are a common, yet serious problem in LTC, rehab, and nursing home facilities. MedPro claims data show that allegations involving pressure injuries occur in more than 1 in 4 cases associated with skilled nursing facilities and almost 1 in 10 cases associated with assisted living facilities.1 Without appropriate care and treatment, pressure injuries can result in pain, infections, disfigurement, hospitalizations, and — as this case illustrates — increased risk of death.

Preventing pressure injuries requires an interdisciplinary approach to care. Although some parts of the approach are very standardized, care also must be tailored to each patient’s specific risks. Pressure injury prevention requires coordination among many individuals, including the multiple disciplines and teams involved in developing and implementing the care plan.

To learn more about preventing pressure injuries, see MedPro’s Risk Resources: Preventing Pressure Injuries in Older Adults, the Agency for Healthcare Research and Quality’s (AHRQ’s) On-Time Pressure Ulcer Prevention (part of AHRQ’s Safety Program for Nursing Homes), and the National Pressure Ulcer Advisory Panel website.


1 MedPro Group. (2022). Senior care: A coded case analysis. Retrieved from www.medpro.com/documents/10502/5086245/Senior+Care_Claims+Data+Analysis_2022_MedPro+Group.pdf

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