Pressure ulcers typically develop when a resident’s care plan isn’t consistently followed—especially during times when staffing fluctuates or a resident’s schedule shifts. In local practice, we often see patterns like:
- Weekend and holiday coverage leading to delayed checks or fewer hands for repositioning
- Admissions and transfers (from hospitals or rehab) where risk levels change, but assessments aren’t updated quickly
- Care interruptions when a resident is temporarily off the usual routine for appointments or therapy
Even if the facility has policies on paper, neglect claims frequently turn on whether staff actually followed the plan: turning schedules, skin checks, hygiene routines, and wound treatment timelines.


