In the Vancouver area, families often tell us the same patterns—especially when a resident has mobility challenges, complex health needs, or periods where staffing feels stretched.
These situations can include:
- Delayed response after first skin changes: A red or irritated area is noticed, but the follow-up assessment and wound plan aren’t prompt or detailed.
- Care plan updates that don’t match what’s happening: The chart may show turning/skin checks are “scheduled,” but the resident’s condition suggests those steps weren’t carried out consistently.
- Transfers between levels of care (or frequent changes in caregivers): New teams may not fully carry forward the resident’s risk level, turning needs, or skin-care instructions.
- Moisture and hygiene gaps: Pressure injuries can worsen when incontinence care, moisture management, and cleansing protocols aren’t handled properly.
A facility’s explanation matters—but so does the medical timeline. In many cases, what’s missing from documentation (or what appears late) becomes just as important as what’s present.


