Pressure injuries — also called bedsores, decubitus ulcers, or pressure ulcers — are wounds that develop when sustained pressure cuts off blood flow to skin and underlying tissue. They are among the most preventable injuries in nursing home care, yet they remain a leading indicator of neglect in skilled nursing facilities and assisted living communities throughout California. When a facility fails to prevent or promptly treat pressure injuries, California’s Elder Abuse and Dependent Adult Civil Protection Act gives families specific legal tools to hold facilities and their staff accountable.
By Paul H. Kang, Attorney · Los Angeles Bar Association Elder Law Panel Counsel · Last updated 2026
When a person enters a nursing home, the facility assumes legal responsibility for that resident’s care. State and federal regulations require facilities to assess every resident’s risk of skin breakdown, to develop and follow an individualized prevention plan, and to provide enough trained staff to reposition residents and monitor their skin.
Unlike many injuries, pressure injuries do not happen suddenly or by chance. A resident does not develop a Stage 4 wound overnight. These injuries develop in stages over days and weeks while staff fail to reposition the resident, fail to inspect the skin, fail to keep the resident clean and dry, or fail to escalate an early-stage wound to a physician. Because the prevention protocols are well established and the warning signs are visible, an advanced pressure injury is one of the clearest indicators that a facility broke down somewhere in the chain of basic care.
Families are often the first to notice. The resident develops a wound on the heel, hip, or tailbone. The wound gets larger or deeper between visits. The facility’s answers about how the wound developed and how it is being treated become vague or inconsistent.
California’s Elder Abuse and Dependent Adult Civil Protection Act (Welfare and Institutions Code section 15600 and following) was written to address exactly this. It treats this kind of neglect not as ordinary negligence but as a distinct civil wrong, and it gives families specific remedies that go beyond what general personal injury law allows.
Stage 1 — Intact skin with non-blanchable redness
The skin is not broken but shows persistent redness that does not turn white when pressed. The area may feel warmer, firmer, or softer than surrounding skin. Stage 1 injuries are fully reversible with prompt intervention, but they are also a clear warning sign that a facility is failing its repositioning obligations.
Stage 2 — Partial-thickness skin loss
The outer layers of skin (epidermis and dermis) are damaged or lost. The wound appears as a shallow open ulcer with a red or pink wound bed, or as an intact or ruptured blister. At this stage the resident is experiencing real pain, and the wound is at risk of progressing rapidly if the underlying cause — sustained pressure — is not eliminated.
Stage 3 — Full-thickness skin loss
The wound extends through the full thickness of the skin into subcutaneous tissue. Fat may be visible, but bone, tendon, and muscle are not yet exposed. Stage 3 injuries can be deep in areas with significant fat tissue, such as the buttocks, and may involve undermining or tunneling. These wounds require weeks or months of specialized wound care and carry a serious risk of infection.
Stage 4 — Full-thickness tissue loss with exposed bone, tendon, or muscle
The wound reaches bone, tendon, or muscle. Osteomyelitis (bone infection) is a common complication and can be life-threatening. Stage 4 pressure injuries are catastrophic, often irreversible, and are associated with significant mortality in elderly patients. When a resident reaches Stage 4, it almost always reflects a prolonged period of unaddressed neglect.
Pressure injuries develop when sustained pressure on the skin cuts off blood flow to the tissue beneath. Facilities and their staff can prevent virtually every pressure injury with proper protocols, which makes these wounds among the strongest indicators of neglect when they appear. Common causes and contributing factors include:
Failure to reposition — bedridden and immobile residents must be turned or repositioned at least every two hours. When staff skip repositioning rounds, pressure builds on bony prominences (heels, sacrum, hips, shoulder blades, back of the head) and tissue begins to die.
Inadequate support surfaces — pressure-relieving mattresses, overlays, and specialized cushions reduce interface pressure below capillary closing pressure. Facilities that use standard hospital mattresses for high-risk residents without therapeutic overlays are failing a basic standard of care.
Moisture and incontinence — skin that is consistently wet from urine, stool, or perspiration loses its structural integrity and breaks down far more rapidly under pressure. Incontinence care plans that are not implemented promptly allow maceration that accelerates skin breakdown.
Poor nutrition and hydration — protein, vitamin C, zinc, and adequate hydration are required for tissue maintenance and wound healing. Residents who are malnourished or dehydrated develop pressure injuries more readily and heal more slowly.
Inadequate wound assessment — California regulations require regular skin assessments for all residents and more frequent assessments for high-risk individuals. Facilities that fail to detect early-stage injuries allow wounds to progress to severe, life-threatening stages that could have been stopped.
California’s Elder Abuse Act treats pressure injury neglect as a distinct civil wrong that requires specific proof. To recover under the statute’s enhanced damages provisions, plaintiffs must show:
1. The defendant had care or custody of an elder or dependent adult
2. The defendant knew the resident was at risk for pressure injuries (documented in admission assessments or care plans)
3. The defendant failed to implement or follow the required prevention protocols
4. The failure was committed with recklessness, oppression, fraud, or malice — not ordinary negligence
The factual case is built from facility records and expert testimony. Records that matter include:
Wound care and nursing notes — what was documented about skin condition, repositioning, and wound treatment (or what was not documented)
Braden Scale assessments — the industry-standard risk assessment tool that determines what preventive interventions a resident requires
Care plans and MDS assessments — what the facility committed to providing and how it assessed the resident’s needs
Turn-and-reposition logs — whether staff documented completing repositioning rounds on schedule
Photographs — images showing the wound’s progression over time
Staffing schedules and assignments — who was responsible for the resident’s care and how many residents each aide was managing
State survey reports — whether the facility had prior citations for pressure injury failures
The medical case requires expert testimony from wound care specialists, geriatric nurse practitioners, or geriatric physicians who can establish what the standard of care required and how the facility’s failures caused or worsened the resident’s injuries.
When the Elder Abuse Act applies to a pressure injury case, damages may include:
Economic damages — medical expenses for wound care, surgical debridement, skin grafts, hospitalization for infection or sepsis, and the cost of additional care needed because of the injury
Pain and suffering damages — compensation for the resident’s physical pain and emotional distress, recoverable by the resident if living or by the resident’s heirs if the resident has died. This survival of pain and suffering damages after death is the most distinctive feature of California’s Elder Abuse Act and is unavailable in ordinary negligence cases
Attorney’s fees — Welfare and Institutions Code section 15657 authorizes attorney’s fees against defendants found liable for elder abuse by clear and convincing evidence
Punitive damages — in cases of malice, oppression, or fraud, additional damages designed to punish and deter
Wrongful death damages — when an untreated pressure injury leads to fatal infection or sepsis, surviving family members can also pursue a claim for their own loss
The interaction between elder abuse damages, survival action damages, and wrongful death damages is technically complex and depends on the specific facts of each case. We will analyze which combination of claims fits a given situation during the initial consultation.
A pressure injury (also called a bedsore, decubitus ulcer, or pressure ulcer) is a wound caused by sustained pressure that cuts off blood flow to the skin and tissue beneath. It becomes neglect under California’s Elder Abuse and Dependent Adult Civil Protection Act when a facility responsible for an elder or dependent adult’s care recklessly fails to follow the well-established protocols that prevent these wounds — such as repositioning, skin assessment, pressure-relieving surfaces, and nutrition support. Because pressure injuries are almost always preventable, an advanced wound often reflects a failure of basic care.
Watch for persistent redness over bony areas (heels, hips, tailbone, shoulder blades, back of the head) that does not fade, blisters or open sores, broken skin, foul odor from a wound, drainage on bedding, fever or signs of infection, and increased pain or discomfort when lying or sitting. Also watch for a facility that is vague about how a wound developed or how it is being treated. If you notice these signs, photograph the wound, keep dated notes, and request the resident’s medical and wound-care records.
The most important evidence includes the facility’s wound-care and nursing notes, Braden Scale risk assessments, the resident’s care plan and MDS assessments, turn-and-reposition logs, and staffing records showing who was responsible for care. Photographs documenting the wound’s progression over time are especially powerful. Medical records from outside providers (emergency rooms, hospitals, wound clinics) and expert testimony from a wound-care specialist about the standard of care complete the picture.
Yes. When an untreated pressure injury leads to a fatal infection, sepsis, or other complications, California’s Elder Abuse Act allows surviving family members to recover the resident’s pain and suffering damages even after death — an exception to the general rule that pain and suffering damages die with the victim. A wrongful death claim may also be available to the resident’s heirs for their own loss. Both claims can typically be pursued together.
Yes. We represent residents and families harmed by pressure injuries at skilled nursing facilities (SNFs), residential care facilities for the elderly (RCFEs), assisted living communities, board and care homes, and adult day care programs. Any facility responsible for the care of an elder or dependent adult can be held accountable when it fails to prevent or properly treat a pressure injury.
Most elder abuse and neglect claims involving pressure injuries must be filed within two years of the injury or the resulting harm. When a pressure injury leads to death, a wrongful death claim generally must be filed within two years of the date of death. Statutes of limitation can be easy to miss and key evidence can disappear over time, so contact an attorney as soon as you suspect a pressure injury was caused by neglect.
Q: What is Elder Abuse and Neglect A: Some examples of elder abuse are when someone hits, slaps, pinches, pushes, kicks, restrains, confines an elder.
