Pressure ulcers (also called bedsores) typically form when skin and tissue are exposed to sustained pressure, friction, or shearing—especially over bony areas. Medically, that often means a resident’s care plan required consistent prevention steps such as:
- Regular repositioning/turning
- Skin assessments at appropriate intervals
- Prompt response to early redness or breakdown
- Proper wound care and monitoring
- Support with mobility, hygiene, and nutrition as needed
In practice, the problem is frequently not one dramatic mistake. It’s more often a pattern—missed documentation, inconsistent staff follow-through, or a care plan that doesn’t match the resident’s changing risk.


