Stage 4 Pressure Ulcer

Stage four pressure ulcers are the final, worst stage of pressure injuries. They may point to nursing home neglect, meaning the staff has left the resident in one position for a long time or failed to treat the pressure sore in its earlier stages. 

If you or someone you love has suffered stage four bed sores, it’s important to ask for legal help and investigate the issue further. In this article, we will define stage four pressure ulcers and their causes, possible consequences, and legal implications.

What are Pressure Ulcers (Pressure Sores)?

Pressure ulcers are localized injuries that happen when people spend long periods in one position, usually when they’re bedridden or in wheelchairs. The affected area suffers constant pressure, which restricts blood flow and damages the tissue, causing skin cells to lose oxygen. As a result, skin cells die and break down, forming a pressure sore. 

Stages of Pressure Ulcers

Healthcare providers use the stage system to categorize pressure sores and determine their severity and treatment requirements. They start as barely visible bruises, and if left untreated, can worsen and become a life-threatening condition.

The four stages of pressure sores are:

• Stage one – The mildest form of pressure ulcer presents as a non-blanchable redness of intact skin, which may feel warmer or cooler than the surrounding area. It is more difficult to notice on darker skin tones. This occurs when blood flow is first restricted.
• Stage two – In stage two, the skin breaks down, creating an open sore that may affect the first two layers of the skin but not the tissue underneath. 
• Stage three – In stage three, the wound penetrates deeper, with skin loss affecting all three layers of the skin. The muscles underneath are still intact.
• Stage four – The wound affects all three layers of the skin, exposing muscles, tendons, and even bones. The open wounds are prone to infection, and necrosis is frequent. A stage four pressure ulcer usually cannot be healed by restoring blood flow to the area.

There are other possible presentations of pressure injuries where the skin is intact, but the tissue underneath isn’t. A blood-filled blister or dead tissue points to a suspected deep-tissue injury.

Stage 4 Pressure Ulcers: The Most Severe Stage

A stage four pressure sore is the most serious stage of pressure injuries. It causes significant discomfort and pain and poses a high infection risk.

Characteristics of a Stage 4 Pressure Ulcer

Stage four pressure injuries are severe wounds marked by deep tissue damage that extends through the skin, revealing muscle, tendon, or even bone. Due to the exposed tissues, these open sores pose a high risk for severe infections, including sepsis and bone infections.

At stage four, there is a significant risk for necrosis, where the skin and underlying tissue die off due to a cutoff of blood supply. Patients may experience intense pain, swelling, and a foul odor from infection of the open wound, which can be distressing and isolating. Symptoms like blackened tissue and pus are common. 

To treat pressure sores at this stage, healthcare providers must remove dead tissue, use antibiotic therapy, and provide intensive wound care to prevent the body from attacking its tissues and triggering sepsis. Procedures like skin grafts and surgery may be necessary.

Common Locations

Decubitus ulcers usually appear on bony areas that are directly pressed against an external surface. This typically includes:

• Shoulder blades
• Heels
• The back of the head
• Tailbone
• Ankles
• Hips

Associated Complications

Stage four pressure ulcers can lead to several life-threatening complications. Due to their depth, they are at risk of bacterial infections. Common complications include:

• Skin infection 
• Joint infections
• Osteomyelitis (bone infection)
• Sepsis
• Septic shock 
• Death 

Causes of Stage 4 Pressure Ulcers in Nursing Homes

Pressure injury development can be prevented in most cases, and with proper treatment, these deep wounds do not have to progress to their worst, most dangerous stage. In this section, we will discuss risk factors and common causes of pressure injuries. 

Neglect and Inadequate Care

In many (but not all) cases, residents develop bedsores because of nursing home neglect and inadequate care. Nursing home staff can fail to reposition patients who have difficulty moving and use medical equipment to relieve pressure, cutting off circulation. 

Severe sores are more likely to develop when nurses do not provide appropriate skin care, such as hygiene measures, moisture barriers, incontinence care, and moisturizing. Dry, irritated, and fragile skin is more likely to tear and become an open wound.

Hydration and nutrition are the third aspect of sore prevention, as they ensure the skin is elastic and the body has all the nutrients it needs to repair itself. When residents are malnourished and dehydrated, they are more likely to suffer pressure injuries.

Underlying Medical Conditions

Nursing home residents are more susceptible to pressure sores due to their age, but also other health conditions that are more likely to affect them. This includes illnesses and fractures that force them into prolonged bed rest, such as spinal cord injuries, hip fractures, late-stage cancer, and stroke. 

Bed sores are also more common with diabetes, as the illness impairs circulation and delays wound healing. The lack of adequate nutrition can also increase the risk of pressure ulcer development.  

Inadequate Staffing and Training

Treating pressure sores requires sufficient, well-trained staff that can provide proper medical care to residents with limited ability to move. 

In understaffed nursing homes, caregivers are often stretched thin, leaving them less time to provide essential tasks like repositioning and skin care. They may also fail to notice and fight infection on time.

The lack of training can make the situation even worse, as they may fail to recognize the early symptoms of pressure sores, promote healing, and ease pressure properly.

Legal Implications of Stage 4 Pressure Ulcers

Nursing homes must do everything within reason to prevent bedsores and protect their residents from complications if sores develop. If they fail, they can be held responsible.

Nursing Home Negligence and Liability

Most pressure sores can be prevented, and even if they appear, healthcare providers can usually treat them before the wound exposes muscles and bones. If they fail, this may point to neglect.  

If they result from inadequate care or disregard for protocols, stage four pressure ulcers can be considered evidence of negligence or malpractice and grounds for a legal claim.

Nursing homes can be liable if they:

• Fail to adhere to care standards
• Fail to hire and train enough staff
• Fail to properly document care
• Fail to implement preventive measures for pressure ulcers

If found liable, nursing homes can face consequences, including financial compensation to plaintiffs in personal injury lawsuits, fines, inspections, mandatory training programs, and even license suspension or revocation.

Proving Negligence

In every nursing home abuse case, it’s important to prove that the negligence directly caused the injuries and that the care required was the home’s responsibility. 

The elements of each negligence case include:

• Duty of care – This includes a legal duty to provide skin assessment, repositioning, adequate skincare, and timely medical attention. 
• Breach of duty – We must prove that the duty of care has been breached and that the staff failed to do what they are legally required to do. 
• Causation – We must prove that the home’s action or inaction directly led to the damages, such as injury, infection, or death.  
• Damages  – The action or inaction must have led to damages, such as injury, medical bills, or pain and suffering.

Types of Compensation

Nursing home resident and their families can receive the following types of compensation:

• Medical expenses
• Pain and suffering
• Punitive damages in cases of gross negligence

If the pressure sore resulted in the wrongful death of the resident, the damages may include funeral expenses and the loss of companionship.

How a Lawyer Can Help if You or a Loved One Has Suffered Pressure Injuries

A nursing home injury lawyer experienced with pressure injury cases can be your greatest ally, as they know how to handle the investigation, the nursing home and its insurer, and the legal system. This is how they can help nursing home residents and their families. 

Investigating the Case

A nursing home injury lawyer can help you reveal the circumstances that led to the pressure ulcer developing and progressing to stage four. They can:

• Gather evidence – Attorneys can efficiently gather photographic evidence, medical records, facility documentation, and surveillance footage to show what led to the development of the pressure injury.
• Interview witnesses – They know exactly what to ask to determine liability and strengthen your case. Your attorney can interview staff, other residents, and family members.
• Consult experts – If necessary, your attorney will gather expert testimonies from medical and other relevant professionals. 

Negotiating with the Nursing Home

Most nursing home injury lawsuits are settled outside court with the nursing home’s insurance company. Your lawyer will have decades of experience negotiating with insurance companies and dismantling their tactics. 

Insurers often try to minimize damages, reduce the nursing home’s blame, or offer the family a low settlement. With a lawyer by your side, you won’t have to worry about receiving an unfair settlement. 

Litigating the Case 

In some cases, pressure sore injury lawsuits must be handled in court, especially if there have been extreme consequences and the insurer refuses to offer fair compensation. 

Attorneys with decades of experience will be prepared to file a lawsuit and represent you in court, manage all legal procedures, cross-examine witnesses, and manage the entire process with minimum stress for the plaintiff.

Also, many lawyers work on a contingency fee basis, meaning that you pay them from the compensation you receive and don’t pay anything unless they win your case. 

Secure Expert Legal Counsel! 

If you suspect your loved one has suffered from a stage four pressure ulcer, you can hold the healthcare provider and the facility responsible. Contact the Nursing Home Law Center for a free consultation, and we will discuss the case with you, explain your rights, and outline your legal options.

No one deserves to suffer the pain of a severe pressure ulcer, and anyone who allowed it to happen must be held accountable. Call (800) 926-7565 or complete our online form to schedule a free conversation with a nursing home injury attorney.