Braden Scale

Bedsores are a common occurrence for patients with limited or restricted mobility in nursing homes. There are tools to help assess a patient’s risk factors for developing a pressure ulcer, and medical professionals develop preventative treatment plans based on the results.  

In this article, we’ll discuss the most popular tool—the Braden Scale—including what it is, how it’s used, and your legal rights if you or your loved ones develop bedsores while in medical care. 

Nursing Home Law Center can help you seek compensation for your injuries when ready. 

Understanding Bedsores (Pressure Ulcers)

Bedsores, or pressure ulcers, are a type of pressure injury. They occur when constant pressure causes damage to the skin surface or underlying soft tissue. The pressure could result from friction, moisture, tension, and other motions that can cause damage over extended periods if not moved.

Bedsores develop on bony areas of the body, including:

• Sacrum
• Low back
• Hips
• Tailbone/Butt
• Heels
• Knees
• Elbows
• Shoulders
• Back of the head
• Ears

There are four stages of bed sores, which will get more painful and severe the longer the pressure is applied.

• Stage 1: A stage one bedsore presents like a bruise. It appears like a red, blue, or purple area on the skin. It can feel warm, burn, or itch.
• Stage 2: The skin will break in stage 2 bedsores. They look like open wounds, almost like blisters or torn skin. The skin around the wound will start to look discolored and be painful to the touch.
• Stage 3: The bedsore continues to deepen at stage 3. It looks like a crater in the skin, and it can be challenging to see inside the wound. Eschar (thick black tissue) or slough (yellow, black, gray, or white slimy tissue) may be present. The surrounding tissue area can also darken in color. 
• Stage 4: This is the most severe form of bedsores. The damage spreads to joints, bones, or muscles. You can develop a bone infection called osteomyelitis or a blood infection called sepsis. Eschar and slough may also be present. 

Medical professionals should reposition bodies to prevent bedsores from developing. They can prop the limb up, apply powdered talc, or place a special dressing to protect the area. A skin assessment can usually detect bed sores. 

Why is Pressure Ulcer Development a Serious Concern in Nursing Homes?

The Agency for Healthcare Research and Quality reports that more than 2.5 million Americans develop pressure ulcers yearly, and treatment can cost over $11 billion annually. [1] Many of these cases come from home healthcare agencies, hospitals, and nursing homes and can lead to serious complications.

• Sepsis: Elderly patients risk developing sepsis, which occurs when an infection enters the bloodstream. It can also cause septic shock, a drop in blood pressure that can damage the lungs, liver, or kidneys. 
• Bone infections: Severe bedsores can cause bone infections (osteomyelitis) and joint infections (septic arthritis), significantly impacting a patient’s mobility and limb function.
• Bacterial infections: Bedsores can contract infections, including staph, necrotizing fasciitis, gangrene, and more. These infections can destroy muscle tissue and spread throughout the body. 
• Cellulitis: Skin and soft tissues can develop cellulitis, leading to swelling and redness. The skin can also be warm, making a skin assessment crucial.
• Abscess: Pus and pockets of infection can develop under the skin. 
• Amputation: Stage 4 bedsores may only be treated by amputating limbs to stop the spread of infection. 
• Cancer: If a wound cannot heal over time, it can lead to cancer. This is called a Marjolin ulcer, which can lead to squamous cell carcinoma.  
• Death: Bedsores can lead to death if left untreated. These bacterial infections can cause death, especially if the body goes into septic shock. Stage 3 and 4 bedsores are more likely to end in death. 

Pressure ulcers are excruciating and can impact the residents’ quality of life. They can limit the following.

• Mobility: Patients may be unable to move due to pain, itchiness, burning, etc.
• Social interactions: The wounds may be embarrassing, and patients can self-isolate.
• Mental health: Some may develop depression, anxiety, body image issues, and other psychological conditions as a result of pressure sores. 

Pressure ulcer treatment, including medication, care, supplies, nursing staff, and more, can be costly. Severe cases may also require surgery, hospitalization, and physical therapy, which can be a significant financial burden. 

The Braden Scale for Predicting Pressure Sore Risk Factors

Healthcare professionals use various tools to assess the likelihood of developing bed sores. These tools provide insight into the risk for pressure sores, while a skin assessment can help determine if one is already present. One of the most popular tools is the Braden Scale, which we’ll discuss below in detail.  

What is the Braden Scale?

The Braden Scale is a tool for assessing risk for pressure injuries. First created in 1987 by two nurses, the National Institute for Health reports that it is still the most frequently used bed sore assessment tool today. 

The Braden Scale has six risk assessment categories, scoring patients on one to four. The scores in each category are totaled together to find the Braden score. The lower a patient’s score, the higher their risk factor of developing pressure ulcers. 

Six Subscales of the Braden Scale

The breakdown of the six subcategories of the Braden Scale is as follows.

• Sensory Perception: Sensory perception assesses the resident’s ability to feel discomfort or pain. Patients who can’t feel pain won’t be prompted to move independently or communicate discomfort. Sensory perception can also help assess degrees of paralysis. It is scaled: completely limited (1), very limited (2), slightly limited (3), or no impairment (4). 
• Moisture: Exposure to moisture can increase the risk of skin breakdown. Skin moisture includes urine, sweat, wound drainage, stool, and more. The longer the skin is exposed to moisture, the higher the risk of developing bedsores. It’s scaled as follows: constantly moist (1), very moist (2), occasionally moist (3), or rarely moist (4).  
• Activity: Residents’ level of physical activity can contribute to the high risk factor of developing pressure injuries. They can use walkers or canes to support their physical activity. The scale is as follows: bedfast (1), chairfast (2), walks occasionally (3), or walks frequently (4). 
• Mobility: This measures a patient’s ability to change or control body position, typically within a bed or chair. It is rated as completely immobile (1), very limited (2), slightly immobile (3), or no limitation (4). 
• Nutrition: This category assesses the amount and nutritional quality of your diet. An unhealthy diet or inadequate nutrition can contribute to a patient’s skin breakdown and lack of healing. A liquid dietary supplement may be necessary. Nutrition is rated very poor (1), probably inadequate (2), adequate (3), or excellent (4).
• Friction and Shear: This risk factor category measures a patient’s strength and ability to maintain their position within a bed or chair. If the patient slides down or is restless, it can cause increased friction on the skin, which can cause tears. The scale ranges from problem (1), potential problem (2), or no apparent problem (3). 

Together, these scores determine how likely a patient is to develop bedsores. The lower the score, the higher the risk, and appropriate precautions should be taken to prevent them from developing pressure injuries.

Interpreting Braden Scale Scores

Medical professionals tally these results to determine a patient’s pressure ulcer risk. 

• Severe risk (Less than 9): This is the highest risk, and patients in this category require frequent monitoring, especially if they have a low sensory perception score. Major and frequent changes in body position can prevent bedsores. 
• High risk (10-12): Patients at high risk of developing bedsores may require additional equipment to help prevent bedsores or skin breakdown, especially when transferring patients. They must ensure their bodies are frequently moved or repositioned and take extra care to maintain their skin health. 
• Moderate risk (13-14): Patients with a moderate risk assessment score likely need to change their diet and hygiene to prevent pressure ulcers. Additionally, patients must learn about body positioning and how often they should reposition. If they cannot reposition, their caretakers must ensure they are moved at regular intervals. 
• Mild risk (15-18): Patients demonstrate some risk factors for developing bedsores. They should be educated on skin hygiene, make dietary changes, and increase physical activity as necessary.
• No risk (19-23): Developing pressure injuries is unlikely. They should be routinely monitored to ensure no changes in mobility that would change their rating. 

A patient’s risk for developing bed sores can change, so it’s essential that medical staff routinely re-evaluate the patient and make treatment adjustments as needed. Frequent or significant changes in positioning can prevent pressure sores regardless of the risk level. 

Using the Braden Scale for Bedsore Prevention

A patient’s pressure injury risk helps determine their treatment plan. 

Pressure Ulcer Risk Assessment and Care Planning

The Braden Scale helps caregivers assess a patient’s risk and develop individualized care plans. This can include creating a specialized care team comprising their primary care doctor, nurses, physical therapist, dietitian, dermatologist, wound care specialist, etc. 

Care plans may include increasing nutritional intake, using a protective skin barrier, a physical therapy consult, and more.

Medical professionals can help ensure patients do not develop pressure ulcers by taking proper precautions based on their Braden Scale score.

Implementing Preventive Measures

Nursing homes can take several interventions and preventative measures to help avoid pressure injuries.  This can include:

• Repositioning intervals and turning schedules: Nurses should reposition patients at set intervals to relieve the pressure from vulnerable areas. Occasional slight changes help.
• Skincare and moisture management: To prevent pressure-related discomfort, the skin should remain clean, dry, and moisturized. Incontinence should also be managed to prevent urine or feces from causing bedsores. Protective skin barriers decrease the risk. Nurses only moisturize dry, unbroken skin.
• Support surfaces: Specialty equipment, including mattresses, pillows, and cushions, can relieve pressure from at-risk body parts. They help redistribute the pressure so there’s less friction in vulnerable areas.  
• Nutritional support: To promote skin health, patients may need to change their diet and increase their nutritional intake. A dietitian can help educate patients on their needs and monitor nutritional intake. Inadequate nutritional intake can slow healing and lead to a pressure ulcer.
• Activity: To ensure sufficient muscle strength, patients may receive physical therapy. Therapists should avoid massaging pressure points.

Pressure injury prevention should be taken seriously for at-risk patients of all levels. 

Nursing Home Negligence and Bedsores

Nursing homes have a duty of care to their patients, and when they do not uphold it, they can be held liable for their actions. 

Failure to Prevent Bedsores

Suppose you or your loved one develops bed sores while in a nursing home; it can be a sign of nursing home negligence. Pressure ulcers develop from being in the same position for too long. They can also occur from mishandling, poor hygiene, malnutrition, etc. 

Nursing homes are responsible for caring for vulnerable patients, including assessing their risk and implementing preventative measures based on their risk assessment scale. 

Holding Nursing Homes Accountable

Bedsore victims have various legal options available to hold nursing homes accountable for bedsore-related injuries. 

• Official complaint: You can file a complaint with your state health department. Timely and accurate reporting is crucial.
• Nursing home complaint: You can file a complaint directly with the nursing home.
• File a lawsuit: You can sue the nursing home for negligence and recover compensation for you or your loved one’s personal injuries. 

A nursing home injury lawyer can help you navigate your legal options. 

The Role of a Nursing Home Injury Lawyer

Nursing home injury lawyers are your advocate throughout the process. They protect your rights so you can get the compensation you deserve. 

Investigating Bedsore Cases

Lawyers can investigate the circumstances surrounding bedsore cases. They can:

• Review medical records: Lawyers obtain official medical records from doctors, hospitals, nursing homes, etc., to determine your treatment plan and identify violations.
• Locate video footage: Nursing homes and hospitals often have surveillance footage available. 
• Interview witnesses: Lawyers will talk to care staff, other patients, your family, and witnesses to determine what happened.

Lawyers take your evidence and investigate it further to build your case.

Proving Negligence

You must prove negligence and establish the nursing home’s liability for bedsore injuries. This can be a complicated process, which is where a personal injury attorney can help. 

• Establish duty of care: Your lawyer must establish that the nursing home has a duty of care to you. You were a patient or under their treatment and should have received an accurate assessment. 
• Breached duty of care: The nursing home did not uphold its duty of care. You faced injury or harm while under their care, including a pressure ulcer. 
• Causation: The nursing home’s breach of care is what directly led to your bedsores.
• Damages: You faced significant damages as a result, including physical, emotional, and financial. 

Personal injury lawyers help build your case, starting with proving negligence.

Seeking Compensation for Damages

Nursing home injury lawyers help you recover damages in a bedsore case. These can include:

• Medical expenses: Doctor’s visits, hospital stays, mental health treatment, medication, ambulance rides, physical therapy, dietitians, etc. can be costly. 
• Pain and suffering: A pressure ulcer can take an emotional toll on patients, leading to emotional damage.
• Punitive damages: If the nursing home is found guilty of gross negligence, it can also be ordered to pay punitive damages. This is to punish them and prevent the conditions from occurring again. 

Nursing home lawyers work to recover maximum compensation based on your bedsore case and hold all responsible parties accountable. 

Secure Expert Legal Representation! 

Bedsores and pressure injuries can be excruciating and isolating. Nursing Home Law Center is here to investigate cases of bedsore neglect and help victims seek justice. Our team of skilled lawyers will help you hold negligent facilities accountable and start your recovery journey.

Contact us today at (800) 926-7565 or fill out our online form to learn how we can help you recover compensation for your damages. 

References: [1] AHRQ