Pressure ulcers — particularly severe pressure injuries and deep tissue injuries — have long been among the most challenging cases in senior living care. For years, providers and defense teams assumed these wounds were always preventable, and if documentation didn’t prove two-hour turns or consistent repositioning, facilities had little defense.
But new insights in wound care and litigation strategy are reshaping that narrative. In a recent CareAgents webinar, nurse consultant Monica Chadwick and wound care physician Dr. Caroline Fife shared how clinical evidence, thoughtful policy design, and defensible documentation can shift the paradigm in mitigating malpractice claims.
Why Pressure Ulcer Cases Are So Difficult to Defend
Defending pressure injury claims is notoriously difficult. As Monica explained, these cases come with three core challenges:
- Graphic wounds – Large, painful ulcers are difficult for juries to reconcile with claims of “good care.”
- Fragmented documentation – Records may live across treatment plans, physician orders, and nursing notes, rarely in perfect alignment.
- Overly aspirational policies – Facilities often adopt policies that sound good on paper (“we exceed national standards” or “treatment will be initiated immediately”) but are impossible to meet in practice. These statements backfire in litigation.
“When a policy says you’ll meet and exceed standards, how do you defend that? What does exceeding mean? If you can’t prove it, you’ve created liability for yourself.” – Monica Chadwick
The Myth of “Not Documented, Not Done”
One of the most enduring nursing phrases is also one of the most dangerous: “Not documented, not done.”
From a risk management perspective, this belief can hurt nurses under deposition. If a nurse testifies that they document everything, any gap in notes can be spun as proof that care wasn’t provided.
The reality is that modern nursing documents by exception — recording deviations from the norm rather than every sip of water or every repositioning. Training staff on this distinction, and ensuring policies reflect it, is crucial for defensibility.
Causation and Medical Unpreventability
Dr. Fife emphasized the importance of distinguishing between standard of care and causation. A facility might meet the standard of care — timely assessments, treatments, and repositioning — yet a resident may still develop a severe ulcer due to factors outside anyone’s control.
These factors include:
- Low blood pressure and reduced tissue perfusion
- Major surgeries with prolonged immobility
- Peripheral vascular disease
- Malnutrition or low albumin levels
- Vasopressor medications that restrict blood flow
Such conditions can cause tissue death from the inside out, long before surface skin changes appear.
“By the time you see that deep tissue injury, the damage is already done. These wounds evolve — they don’t simply progress like cancer staging. It’s like an apple rotting from the inside.” – Dr. Caroline Fife
This understanding reframes ulcers not as “never events” but as sometimes medically unpreventable events — critical language in both clinical documentation and litigation defense.
Why Photos and Plain Language Matter
Many facilities avoid wound photography, fearing it will be used against them. But as Dr. Fife noted, photos exist anyway — often from hospitals, vendors, or family members. Without facility-controlled photos (with measurements and context), juries may only see the worst-case images.
Accurate photography helps:
- Demonstrate wound size and progression
- Clarify whether lesions are new or evolving from prior conditions
- Counter plaintiff-supplied photos taken at inopportune moments
Just as importantly, clinicians should avoid vague staging language. For example, “stage two” may not apply to every superficial wound — and if ulcers appear to “jump” from stage two to stage four in documentation, it creates the impression of worsening neglect. Photos and precise terminology (e.g., “deep tissue injury evolving”) tell a more accurate story.
Policy Pitfalls to Avoid
Policies and care plans must be realistic and defensible. Common pitfalls include:
- Rigid timelines (e.g., “wound will heal in 60 days”) that are impossible to guarantee
- Absolute promises (“orders will be implemented immediately”) that don’t reflect supply chain or staffing realities
- Aspirational language (“we exceed standards of care”) that invites scrutiny
Instead, policies should emphasize mitigation strategies, staff judgment, and flexibility based on clinical appropriateness.
Litigation Lessons
The speakers shared landmark research and real-world cases that underline why this shift in thinking matters:
- California DOJ Study – Even in 63 top-performing nursing facilities, full-thickness pressure ulcers still occurred, proving they can develop despite excellent care.
- TURN Trial (NIH-sponsored) – Randomized residents to two-, three-, or four-hour turning schedules. Result: no significant difference in ulcer development when residents were on proper support surfaces. The myth of “two-hour turning” as the gold standard was debunked.
- Real cases – Some facilities paid hundreds of thousands in settlements when policies and documentation were weak. Others avoided litigation entirely because thorough documentation and clear causation evidence proved wounds were medically unpreventable.
Key Takeaways for Providers
- Update policies – Keep them realistic, flexible, and defensible.
- Educate staff – Train nurses to avoid jousting, subjective notes, and the “not documented, not done” trap.
- Document causation – Record comorbidities and hemodynamic factors that make ulcers medically unpreventable.
- Use photos – Control the narrative with accurate, measured wound photography.
- Set expectations – Communicate with families about risks, focusing on protecting life-sustaining organs when skin compromise is unavoidable.
Shifting the Narrative
Pressure ulcer claims won’t disappear, but with better understanding and defensible practices, providers can shift the narrative. Ulcers are not always evidence of neglect — sometimes, they’re evidence of complex, unavoidable physiology.
As Dr. Fife concluded:
“We must stop calling these ‘never events.’ Families, clinicians, and juries need to understand: some pressure ulcers are medically unpreventable, even with the best care.”
By embracing this paradigm shift, senior living providers can improve care quality, reduce liability exposure, and defend the good work of their caregivers.
