Pressure sores are one of the most common forms of neglect and abuse. Nursing homes are negligent when they neglect residents they are entrusted to protect. The Steele Law Firm Law Firm.Nursing homes are negligent when they neglect or abuse the very residents they are entrusted to protect. Unfortunately, pressure sores – or bedsores as they are sometimes known – are one of the most common forms of nursing home neglect and abuse.

In fact, the National Pressure Ulcer Advisory Panel Pressure Injury Staging System (“NPUAP”) has determined that a pressure sore should instead be called a “pressure injury.”[1] This constitutes more than just a change in terminology because the new term better describes the actual injury including both intact and ulcerated skin. Accompanying the change in terminology is also a change in the system of staging of pressure injuries.

The NPUAP unveiled these changes at a meeting in April of 2016 and made the updated illustrations of the new staging system available online: (

A pressure injury, formerly known as a pressure sore, is:

Localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.[2]

In other words, a pressure injury includes both ulcerated skin and intact skin. Previously, the term “pressure ulcer” did not technically include damage to the skin. Now, all damage to skin and underlying tissue caused by the failure to move and reposition nursing home residents can be classified under the same “pressure injury” definition..

In addition to changing the terminology, NPUAP also updated the stages of pressure injuries.[3] A stage one pressure injury is now classified by non-blanchable erythema of intact skin: “[p]resence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.”

Stage two is defined as partial-thickness skin loss with exposed dermis. At this stage, “the wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister.”  Stage two pressure injuries are common in the pelvic and heel regions.

A stage three pressure injury consists of full-thickness skin loss described as: “adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible.” The depth of the tissue damage varies based on where the injury is located. Significant adiposity in an area increases the chances of developing more serious wounds.

A stage four pressure injury includes damage so bad that it is often called “unstageable.” This means that the injury includes full-thickness skin and tissue loss. At this point there may be exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and eschar – signs of infection and dead skin – may be present and can obscure the extent of the tissue loss making the injury unstageable.

The final type of pressure injury is a “deep tissue pressure injury.” The NPUAP stated that a deep tissue pressure injury often results from “intense and/or prolonged pressure and shear forces at the bone-muscle interface.” A deep tissue pressure injury is characterized as persistent non-blanchable deep red, maroon or purple discoloration and may include “intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin.”

While these changes may be the new standard, some argue they do not represent a consensus despite the fact the NPUAP is considered one of the top authorities on pressure injuries and their classification.[4] It is true that the new terminology may stand to help injured nursing home residents because the term “pressure injury” allows residents and their attorneys to classify injuries where the skin is still intact, rather than just ulcerated.

This theory already has one doctor who testifies on behalf of nursing home’s worried: “[p]laintiffs are anxious to link the development of pressure ulcers to elder abuse in order to avoid the cap on punitive damages. It seems highly likely that using the term injury will advance the agenda of plaintiffs to equate pressure ulcers with elder abuse.”

Comments like these show that nursing homes and their representatives are afraid the new terminology and classification system will allow injured residents to more easily obtain the justice they deserve.


[2] Id.

[3] Id.