Case Study: Failure to Prevent Bed Sores (Pressure Ulcers)

When Basic Care Is Missed: Bed Sores

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Before we get into this week’s case study, it’s important to understand something simple, but critical:

Bed sores are often preventable.

Also known as pressure ulcers, these injuries to the skin develop when prolonged pressure limits blood flow to the skin and underlying tissue. They most often affect patients who are unable to move on their own—whether in a hospital, rehabilitation center, or nursing facility.

When proper precautions are not taken, what begins as mild irritation can quickly become a serious medical condition due to hospital and nursing home negligence.

What Are Bed Sores?

We have seen how quickly skin breakdown can progress when patients rely entirely on others for care.

Bed sores typically develop in areas where bone presses against the skin, including:

The lower back and tailbone

Heels

Hips

Elbows

Shoulder blades

They are classified into stages based on severity:

Stage I: Redness or discoloration that does not fade

Stage II: Open sore or blister

Stage III: Deeper wound affecting underlying tissue

Stage IV: Severe damage exposing muscle or bone

As these injuries progress, they become more difficult to treat—and far more dangerous.

Prevention Is Part of Basic Care

Preventing pressure ulcers is not a specialized or extraordinary task. It is a fundamental part of patient care.

For individuals who are immobile or medically vulnerable, the standard of care generally includes:

Repositioning the patient regularly

Using pressure-relieving mattresses or supports

Monitoring skin condition consistently

Keeping the skin clean and dry

Supporting proper nutrition and hydration

We have seen that when these steps are followed, pressure ulcers can often be avoided entirely.

How These Injuries Happen

In many of the cases we review, bed sores are not the result of a single mistake—but a series of missed opportunities.

We have seen breakdowns in care such as:

Patients not being repositioned for extended periods

Early signs of skin irritation going unnoticed or undocumented

Delays in responding to worsening wounds

Inadequate staffing or supervision

Poor communication between members of the care team

When these gaps occur, a preventable condition can quickly escalate into a serious injury.

The Consequences Can Be Severe

What begins as a small area of redness can develop into a life-threatening condition.

Untreated or poorly managed bed sores can lead to:

Serious infections, including sepsis

Tissue death (necrosis)

Bone infections

Chronic pain

Extended hospital stays

Significant decline in overall health

In fatal cases, wrongful death

For families, these injuries are often especially difficult—because they raise a painful question: could this have been prevented?

Proving a Pressure Ulcer Case

From a legal perspective, these cases often focus on whether basic standards of care were followed.

To bring a claim, four key elements must be established:

Duty of Care: The provider was responsible for the patient’s care

Breach: Preventative measures were not properly followed

Causation: That failure led to the development or worsening of the injury

Damages: The patient suffered measurable harm

These cases are often built through careful review of medical records, nursing documentation, and expert analysis.

Case Example: A Preventable Decline

An 82-year-old man was admitted to a Michigan hospital following a stroke that left him largely immobile.

Because of his condition, he was identified as high-risk for developing pressure ulcers. Preventative care protocols were put in place, including regular repositioning and routine skin assessments.

But over the course of several days, those protocols were not consistently followed.

Documentation of repositioning was incomplete. Skin checks were irregular. When early signs of redness appeared, they were not escalated or treated appropriately.

Within a week, the patient developed a Stage III pressure ulcer on his lower back.

The wound became infected, requiring intensive treatment and significantly extending his hospital stay. His recovery from the stroke was further complicated by pain, limited mobility, and a decline in his overall condition.

A later review of the records showed that standard prevention measures had not been followed. Medical experts concluded that consistent repositioning and proper monitoring would have likely prevented the injury.

The case was ultimately resolved through a settlement, helping the family manage the additional care and long-term impact.

Your Rights After a Preventable Injury

When someone is placed in the care of a medical facility, there is an expectation that basic needs will be met.

We have worked with families who trusted that their loved one would be monitored, repositioned, and cared for—and later learned that those steps were not consistently taken.

If you or a loved one developed bed sores in a hospital or care facility, it may be worth asking questions about what happened.

These cases often depend on detailed medical records and early investigation. Reviewing care timelines, documentation, and provider actions can help determine whether standards were met.

Contact Hoffer & Sheremet

Bed sores are often preventable. When they occur due to a lack of proper care, the impact can be significant.

At Hoffer & Sheremet, we are committed to helping families understand what happened and whether medical negligence played a role.

If you have questions about a potential case, we offer free, no-obligation consultations.

Call us at (616) 278-0888 or reach out through our online form. We’re here to listen—and to help you take the next step forward.

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