More than 2.5 million Americans develop decubitus ulcers (pressure ulcers) each year while in the care of hospitals, nursing homes, assisted living facilities, and home healthcare providers. For families discovering one of these injuries in a loved one, the experience can be deeply unsettling, raising questions about how it happened, whether it could have been prevented, and what it means for their loved one’s health. Understanding the causes, risk factors, and care standards that exist to prevent these injuries is often the first step toward finding answers.
What Is a Decubitus Ulcer?
A decubitus ulcer is a wound that develops when prolonged pressure on the skin is left unrelieved — commonly in places where bone sits close to the surface, such as the tailbone, hips, heels, and shoulder blades. In medical and legal contexts, the condition is also referred to as a pressure ulcer, pressure injury, pressure sore, or bedsore, and these terms are used interchangeably.
What are the Causes of Pressure Sores? The Four Primary Mechanisms
The primary cause of a decubitus ulcer is sustained pressure restricting blood flow to tissue, mainly in patients unable to reposition themselves independently. When blood flow is cut off for a prolonged period, the surrounding tissue is deprived of oxygen and nutrients, and it begins to break down.
- Sustained Pressure. When a patient remains in one position for an extended period, body weight compresses tissue between the skin and underlying bone. Once that pressure restricts blood flow, oxygen and nutrients can no longer reach the tissue. Without relief, the tissue begins to break down and die (ischemic necrosis). This process can begin in as little as two hours in a bedridden patient, which is why scheduled repositioning is a fundamental standard of care in any professional healthcare setting.
- Friction. Friction occurs when skin rubs repeatedly against a surface — bedding, clothing, or a wheelchair cushion. This force erodes the outer skin layers over time, weakening its protective barrier and making it significantly more vulnerable to pressure sores, especially when the skin is already moist from perspiration or incontinence.
- Shear. Shear occurs when the skin remains stationary while the underlying tissue and bone shift — usually when a patient slides downward in an inclined bed or wheelchair. The opposing forces stretch and tear the deeper tissue and blood vessels beneath the skin’s surface, causing internal damage that may not be visible during a routine inspection.
- Moisture. Prolonged exposure to sweat, urine, or stool weakens the skin’s natural protective barrier, making it more vulnerable to breakdown from pressure, friction, and shear. Moisture softens the outer skin layers and increases friction against surfaces, accelerating tissue damage — particularly in patients who are incontinent or unable to communicate discomfort.
“External and internal factors co-occur to form these ulcers… internal factors such as malnutrition, anemia, and endothelial dysfunction can speed up the process of tissue damage.” — Zaidi & Sharma, StatPearls/ National Library of Medicine(2024).
What Are the Risk Factors for Developing a Decubitus Ulcer?
Certain patients are more vulnerable to pressure ulcer causes than others. The following decubitus ulcer risk factors — whether present individually or in combination — increase the likelihood of injury without proper monitoring and care:
- Immobility. Patients who cannot independently shift their weight depend entirely on caregivers to reposition them regularly.
- Incontinence. Prolonged exposure to urine or stool breaks down and softens the skin (called maceration), making it more susceptible to injury from even modest pressure or friction.
- Poor nutrition and dehydration. Inadequate protein, vitamins, and fluid intake compromise skin integrity and impair the body’s ability to recover from tissue stress.
- Advanced age. Aging skin is thinner, drier, and less elastic; two-thirds of pressure ulcers occur in patients over 70.
- Reduced sensory perception. Neurological conditions and spinal cord injuries may prevent a patient from feeling the discomfort that would normally prompt a position change.
- Medical conditions affecting circulation. Diabetes, peripheral vascular disease, and similar conditions impair blood flow to at-risk tissue and slow wound healing.
- Cognitive impairment. Patients with dementia or altered mental status may be unable to communicate discomfort, making it the caregiver’s responsibility to monitor, reposition, and protect that patient.
Patients in nursing homes and group homes or assisted living facilities face a heightened risk because they carry several of these risk factors at once and rely entirely on the facility’s staff for protection.
What Are the Stages of Pressure Ulcers?
The stages of pressure ulcers are classified by the National Pressure Injury Advisory Panel (NPIAP) according to depth and severity of tissue damage. Early-stage injuries are often treatable and reversible; advanced-stage wounds are serious, slow to heal, and carry the risk of life-threatening infection. The table below outlines each stage of pressure ulcer progression:
| Stage | What It Looks Like | Tissue Involved |
| 1 | Non-blanchable redness of the skin remains intact | Epidermis only |
| 2 | Shallow open wound, abrasion, or blister | Epidermis and dermis |
| 3 | Deep wound; visible fatty tissue | Full skin thickness into the subcutaneous tissue |
| 4 | Exposed muscle, tendon, or bone | Full thickness through fascia |
| Unstageable | Covered by eschar or slough; depth unclear | Unknown until debrided |
| Deep Tissue Injury | Persistent dark maroon or purple discoloration; skin may remain intact | Bone-muscle interface |
When the stages of pressure ulcers advance — sometimes within days — a Stage 3 or Stage 4 wound in a hospital or care facility raises serious questions about whether the standard of care was upheld. Under Florida law, that failure may lead to a medical malpractice claim under Chapter 766 — which has specific pre-suit investigation requirements — or nursing home negligence under Chapter 400. The pressure ulcer attorneys at Warner & Warner can help families understand which avenue applies to their situation.
How to Prevent Pressure Ulcers?
The medical community broadly agrees that preventing pressure ulcers starts with the protocols caregivers are trained and expected to follow consistently. These include:
- Repositioning bedridden patients every two hours and wheelchair users every 15 minutes if possible.
- Performing regular skin inspections at each repositioning, particularly over bony regions.
- Managing moisture promptly to protect skin integrity.
- Ensuring adequate intake of protein, vitamins, and hydration.
- Using pressure-redistributing mattresses, overlays, and cushions for at-risk patients.
These are established care standards that every hospital, nursing home, and care facility in Florida is expected to follow. When a pressure ulcer develops despite these obligations, contact Warner & Warner to discuss your loved one’s situation.
Did a Care Facility Fail Your Loved One? Warner & Warner Can Help.
When a pressure ulcer develops under professional care in Orlando or Central Florida, families have the right to understand what happened and pursue accountability. The pressure ulcer attorneys at Warner & Warner have extensive experience fighting for patients and families against the healthcare systems and insurance companies that resist responsibility. If you believe inadequate care caused the ulcer, contact Warner & Warner for a Free Case Review at 321-972-1889 to discuss your situation. There is no fee unless a recovery is obtained.