When a pressure ulcer appears, don’t rely on verbal reassurances alone. Start a short “evidence checklist” immediately:
- Request a written skin/wound assessment and the resident’s risk level used by the facility.
- Ask for the turning/repositioning schedule (and whether it was followed) for the days surrounding the first signs.
- Get wound care records showing dates, staging, measurements, and treatment changes.
- Preserve communications: emails, discharge paperwork, incident notices, and any written responses to your concerns.
- Document what you observed with dates and times (e.g., when you saw redness, when staff said they would check, when the wound was actually treated).
In New Jersey, missing or inconsistent documentation can become a major battleground later. Taking these steps early helps prevent gaps from turning into “we don’t have that info” arguments.


