By Dr. Gurdeep Arora, MD, CWSP, HPM, HMDC (Wound Care Expert Witness)
In the high-stakes world of medical malpractice litigation, the discovery of a pressure injury (also commonly referred to as a pressure ulcer) is often treated as a “smoking gun”—an immediate, visual indictment of the care provided. However, a wound is rarely a standalone event. To understand its true origin, we must look beyond the skin’s surface and reconstruct the complex clinical environment that allowed it to form.
A proper wound evaluation cannot begin with a preconceived notion or a search for a single failure. It must start from scratch. By reviewing the medical record piece by piece, we can determine whether the evidence supports a medically reasonable explanation or points toward a systemic breakdown in the standard of care.
The central question in every case remains the same: Does the wound make sense given the patient’s underlying condition, their overall health trajectory, and the clinical setting in which they were treated?
A Wound Care Expert Witness Approach: Starting with the Patient
Before ever looking at the wound, start with the patient.
What medical problems did this patient have before the wound developed? Examples include diabetes, heart disease, poor circulation, severe infection, or neurologic conditions such as stroke or advanced dementia. These conditions directly affect how the skin tolerates pressure and heals after injury.
What was the patient’s “functional baseline”? In plain terms, how independent were they? Could they walk? Reposition themselves in bed? Or were they dependent on staff for turning and mobility? A patient who cannot move on their own is at much higher risk for pressure-related wounds.
What was their cognitive status? Could they communicate pain or discomfort? A patient with dementia may not be able to report early warning signs like pain from pressure.
What was their nutritional status? Were they eating well, or declining? Poor nutrition limits the body’s ability to maintain and repair skin.
These factors define the patient’s baseline risk.
This matters legally because the standard of care is judged in context. A high-risk patient requires a different level and type of care than a low-risk, independent patient.
It is also important to recognize that different care settings operate differently. A hospital ICU has very different staffing and monitoring than a long-term care facility. Applying ICU-level expectations to a nursing home setting often leads to incorrect conclusions.
The goal of a clinical review is to bridge the gap between the medical reality of the patient’s frailty and the legal definition of “reasonable care.”
Reconstructing the Timeline
One of the most misunderstood aspects of wound evaluation is timing.
The date a wound appears in the chart is not necessarily when it started. Tissue injury can develop under the surface before it becomes visible on the skin.
The date a wound appears in a medical chart is not necessarily when it started. Tissue injury often develops under the surface long before it becomes visible.
For example, a patient may have normal-looking skin on admission, but underlying tissue damage may already be developing due to immobility or poor blood flow. The visible wound may not appear until days later.
Key questions include:
- What did the skin look like on admission?
- Were there early warning signs like redness or discoloration?
- When was the wound first clearly documented?
- How quickly did the wound progress?
A wound that appears during a period of acute decline tells a very different story than the same wound in a patient whose condition was stable.
Causation in Pressure Ulcer Malpractice Claims
Wounds rarely have a single cause.
In most cases, they result from multiple factors working together. As a pressure ulcer expert witness, I often find that these injuries are not the result of a single oversight; rather, skin is an organ, and like any organ, it can fail—particularly when the body is under sustained or compounding stress.
Consider this example:
An elderly patient with diabetes and poor circulation becomes acutely ill with an influenza infection. They are weak, eating less, and spending more time in bed. They cannot reposition themselves. Over several days, pressure builds on vulnerable areas like the sacrum or heels. A bedsore or pressure injury develops.
Under normal circumstances, the body protects the skin through movement, adequate nutrition, and stable blood flow. In this setting, many of those protections are compromised at the same time.
In this situation, the wound is not caused by one failure. It reflects:
- Underlying disease (diabetes, vascular disease)
- Reduced mobility
- Poor nutrition
- Acute illness
All of these factors combine.
The location of the wound also matters.
For example:
- A wound over the tailbone or heel often suggests pressure
- A wound on the foot in a diabetic patient may suggest poor circulation or neuropathy
Small details can significantly change the analysis.
Even when care appears appropriate, poorly controlled diabetes can impair healing. Elevated blood sugar reduces the body’s ability to fight infection and repair tissue.
These details do not explain the wound alone, but they shape how the body responds.
A wound is rarely a standalone event. To understand its true origin, we must look beyond the skin’s surface.
Understanding SCALE (Skin Changes at Life’s End)
One additional concept that is often misunderstood in litigation is SCALE, or Skin Changes at Life’s End.
SCALE refers to skin breakdown that occurs as part of the body’s natural decline during severe illness or the end of life. As the body begins to fail, it prioritizes blood flow to vital organs such as the heart and brain. As a result, the skin may receive less oxygen and nutrients, making it more fragile and prone to rapid breakdown.
In these cases, wounds can develop even when appropriate care is being provided, including regular repositioning, hygiene, and monitoring.
This is a critical distinction. SCALE-related wounds are considered unavoidable. They reflect the body’s reduced ability to maintain skin integrity, not a failure in care.
For example, a critically ill patient nearing the end of life may develop a rapidly progressing wound despite consistent preventive measures. In that context, the clinical question is not “why wasn’t this prevented,” but whether the care team recognized the patient’s condition and responded appropriately.
Understanding SCALE helps explain why not all wounds indicate neglect. Some are the result of physiologic decline rather than a deviation from the standard of care.
Evaluating the Record
Once the clinical picture is clear, the next step is reviewing the care that was provided.
Key questions include:
- Was the patient assessed regularly for skin breakdown?
- Was a care plan in place based on their level of risk?
- Were interventions adjusted as the patient’s condition changed?
- Were appropriate specialists consulted when needed?
A critical consideration: Was the physician notified when the wound appeared or worsened, and how did they respond?
From a legal perspective, documentation is critical. The medical record is the primary evidence used to evaluate care.
If something is not documented, it becomes difficult to prove it happened.
Consistent documentation supports the care provided. Gaps or conflicting entries make it harder to draw firm conclusions.
The Questions That Tie It All Together
Every wound case comes down to two questions:
- Why did the wound develop?
- Was the care appropriate given what was known at the time?
These are separate questions. A wound can develop even when appropriate care is provided, especially in high-risk patients.
For example:
A fully dependent patient with advanced dementia, poor nutrition, and multiple medical problems may develop a wound despite consistent repositioning and appropriate care.
This scenario is very different from:
A relatively independent patient whose risk factors were not assessed and who did not receive basic preventive measures.
The goal is to determine whether the clinical picture and the care provided align in a way that is medically reasonable.
Practical Takeaways for Attorneys
- Analyze the patient’s baseline risk factors before the outcome.
- Challenge the assumption that the chart date is the wound onset date.
- Identify multiple contributing causes rather than seeking a “smoking gun.”
- Verify if the interventions matched the documented risk level.
- Recognize that even appropriate care does not always prevent wounds in high-risk patients.
For a comprehensive medical-legal case review, contact High Rock Experts today.
About the Author
Dr. Gurdeep Arora, MD, CWSP, HPM, HMDC is a dual board-certified physician in Internal Medicine and Hospice & Palliative Medicine with 20+ years of clinical experience. As a Certified Wound Specialist Physician and Hospice Medical Director, she specializes in high-stakes litigation involving pressure injury causation, opioid safety, and standard of care in nursing homes and hospice settings.
Contact Dr. Arora:
Email: [email protected]
Mobile: (734) 219-5045