In Oregon and across Dane County, families often tell us the same story: the facility “had a system,” but the resident’s skin worsened anyway. Pressure ulcers can develop when a person’s skin is exposed to pressure, friction, and moisture for too long—particularly if they cannot reliably reposition themselves.
Common local-care breakdowns we investigate include:
- Turn-and-reposition routines not followed consistently (or not reflected in wound timelines)
- Skin checks that were delayed, rushed, or missing in the record
- Moisture management failures (incontinence care, barrier protection, hygiene schedules)
- Support surface issues (mattresses/cushions not appropriate, not maintained, or not used)
- Care plan updates not made after the resident’s mobility or condition changed
Pressure ulcers aren’t always preventable in every scenario. But when the medical documentation shows risk was identified and care was not carried out as required, families may have grounds to seek legal relief.


