Nov 20 2025: Risk Management: Pressure Injuries

Allegations related to “facility-grown” pressure injuries remain a frequent cause for lawsuits and claims. This is particularly true as the frailness of residents continues to rise; underlying health conditions and limited mobility increase the likeliness of pressure injury development.

Pressure injury claims are common in the skilled nursing facility sector, although the claim percentages have decreased slightly from 2021 (28.8%) to 2024 (26.7%). This number situates closed claims for pressure injuries as the #2 most common claim, just behind resident falls. The average payout for pressure injury claims in skilled nursing was just shy of $262,000 in 2024.

While pressure injuries in assisted living account for much lesser percentage when compared to skilled nursing, there was a notable increase from 2021 (5.8% of all claims) to 2024 (6.6% of all claims). Pressure injuries in assisted living rank at #4 of the five top claims, but the payouts are higher than skilled nursing facilities with payouts averaging just over $330,000 per claim. The increasing service needs of residents in assisted living, combined with the trend of co-management of resident care needs with home health and hospice services, further heighten risk of pressure injuries in this setting.

A skin integrity program and timely documented interventions are crucial for both types of care settings to decrease the frequency and mitigate severe pressure injuries. These strategies improve resident outcomes while reducing facility liability by demonstrating proactive efforts to prevent these serious and often preventable injuries.

The CNA report includes recommendations for facility leadership and staff to minimize resident pressure injury development. Those risk management recommendations include:

REGULAR SKIN ASSESSMENT/EVALUATION AND INTERVENTION

Perform comprehensive skin assessments/evaluations upon admission/move-in and regularly thereafter. To enhance timely identification, utilize multidisciplinary approaches including caregiver observation and prompt reporting mechanisms with appropriate follow-up to develop workable interventions. Utilize standard risk assessment/evaluation tools to identify residents at risk of skin breakdown and tailor prevention strategies accordingly. It is encouraged to conduct skin assessments/evaluations upon changes in condition as well as upon return to the facility after hospitalization or other stay.

CARE/SERVICE PLANNING

Ensure interdisciplinary care/service plans are reviewed and adjusted as needed. Monitor staff compliance with care/service plan implementation of interventions. Implement a schedule to reposition residents/encourage repositioning of more independent residents who are at risk of pressure injuries, to reduce pressure on bony prominences.

Consistently use special mattresses, cushions, or pads to redistribute pressure; these devices should be selected based on the individual resident’s needs and risks. Ensure residents have adequate, nutritious foods and remain hydrated to support skin health and wound healing. Ensure the skincare regimen includes gentle cleansing, moisturizing, and protecting the skin from moisture and friction.

DOCUMENTATION

Thorough, accurate, and timely documentation can help establish that facility staff follow established protocols, implement evidence-based practices, and act in the resident’s best interest. Comprehensive documentation can help defend against allegations of negligence or inadequate care by providing a clear depiction of assessments/evaluations completed, interventions used, and the resident’s response to treatment.

Include notation of the location, size, stage, and characteristics of the pressure injury. Use objective and descriptive language to paint a clear picture of the resident’s condition. For assisted livings, if home health is managing the pressure injury, it is imperative to have a qualified staff person observe the wound on a regular basis as well and ensure home health nurses document in the resident’s health record.

This documentation can also serve as a record of pressure injury status upon the resident leaving the facility, either temporarily or permanently, and can be beneficial in determining progression of an injury in the subsequent care setting.

WOUND PHOTOGRAPHY

If the facility’s policy or standard of practice includes photographing wounds, a high-resolution digital camera and specialized software can enable staff to take pictures of difficult-to-treat wounds and upload them to an electronic health record, thus facilitating visual wound tracking and treatment evaluation. Inconsistent or unsecured digital imaging techniques, including the use of a personal cell phone to capture pressure ulcer conditions, could diminish credibility and inflate damage awards.

COMMUNICATION AND COLLABORATION

Document communication between and among residents, families, staff, and other health care providers related to expectations and progress. Open and timely communication channels will help in identifying and addressing changes in a resident’s pressure injury status and/or risk. This includes promptly reporting concerns, updating plans of care, and ensuring all stakeholders are “in the know” regarding the resident’s status. Discuss with the resident and legal representative(s) regarding plans of care, changes, and risks and benefits of interventions. These discussions should be summarized via documentation.

TRAINING AND EDUCATION

Provide staff with training in assessment/evaluation techniques and expectations on documenting and reporting condition status and changes. Ensure proper techniques are used for transferring and repositioning. It is encouraged to use a formal competency tracking tool to demonstrate completion of all expected training.

TRACKING/TRENDING

Pressure injury data should be analyzed, tracked, trended, and monitored to determine if interventions are working. Provide data to the quality assurance/performance improvement meetings for additional reviews and recommendations.

For more risk control strategies related to pressure injuries, access the CNA CareFully Speaking publications entitled:

• “Pressure Injuries: Sound Documentation is Key to Defensibility”
• “Photographic Wound Documentation: Ten Guidelines to Help Minimize Digital Imaging Exposures.”

Next month, we will conclude our series on risk management recommendations by covering the importance of adverse event disclosure. For questions about this series, please email Elena Madrid (for skilled nursing facility members) or Vicki McNealley (for assisted living facility members).