Pressure Injury and Wound Care Claims

Pressure injuries, historically called pressure ulcers or bedsores, are staged wounds that develop from sustained pressure on tissue. They are one of the most litigated conditions in skilled nursing because progression is documented in the medical record over time, and because CMS survey standards at 42 CFR Part 483 address them directly.

These claims are unusually difficult to defend for a structural reason: the record itself tells the story. A wound documented at stage two on admission and stage four sixty days later creates a visible timeline, and the defense has to explain each interval. That makes them expensive to defend regardless of merit, which in turn makes defense-inside-limits and retention erosion by defense far more consequential for a skilled nursing operator than for an assisted living one. There is no separate pressure injury coverage grant to buy. The insurance response is to size limits and structure the retention with this claim type in mind, and to recognize that a program built for a light frequency profile will not hold up here.