A pressure ulcer isn’t simply “bad luck.” It usually reflects a breakdown somewhere in the chain of prevention and response—such as:
- inconsistent turning and repositioning
- incomplete skin checks or delayed recognition of early redness
- gaps in wound care follow-through
- failure to adjust care plans when mobility, nutrition, or sensation changes
- staffing and documentation shortfalls that affect resident monitoring
Oregon families often tell us the same story: staff assured them everything was fine, but the record later shows missed risk monitoring or delayed escalation. When that happens, the timeline becomes critical.


