Pressure ulcers are not usually random. They typically reflect a failure in one or more of these areas:
- Skin checks and risk monitoring weren’t done often enough or were documented too late.
- Repositioning wasn’t consistent with the resident’s mobility needs.
- Hygiene and moisture control weren’t properly managed (especially for residents with incontinence).
- Nutrition and hydration needs weren’t addressed when healing requires adequate intake.
- Wound escalation didn’t happen quickly when early redness or breakdown appeared.
Facilities may argue that the ulcer resulted from the resident’s underlying health conditions. That defense can be true in some cases—but it doesn’t erase the facility’s duty to follow an appropriate care plan and respond promptly to warning signs.


