Lee Ann Baldini
Registered nurse, Case manager
Pressure injury and bedsore expert witness
Pressure injury cases are won and lost on one distinction: avoidable or unavoidable. The federal standard at F686 does not require that no resident ever develops a wound. It requires that a resident who enters the facility without pressure ulcers does not develop them unless they were clinically unavoidable, and that a resident who arrives with a wound receives the treatment and services necessary to promote healing and prevent infection and new ulcers.
That makes the record trail decisive. A defensible chart shows risk identified on admission, interventions ordered and delivered, weekly wound measurements that track in one direction, dietitian involvement when intake drops, and physician notification when the wound worsens. A problematic chart shows a Braden score that never changes, repositioning grids with identical entries across three shifts, wound photos that skip two weeks, and a Stage 4 that appears in a hospital record before it appears in the facility record.
The wound itself also has to be staged correctly. Deep tissue injuries, unstageable eschar, moisture-associated skin damage, and Kennedy terminal ulcers are different findings with different implications, and mislabeling is common on both sides of a case.
Records to request
- Braden or Norton scale scores from admission forward
- Skin assessments on admission and weekly skin checks
- Turning and repositioning records, plus the assignment sheets for those shifts
- Wound assessments with measurements, staging, and photographs
- Treatment administration records (TAR) and wound care orders
- Support surface and mattress orders, delivery records, and maintenance
- Dietitian assessments, weight records, albumin and prealbumin labs
- MDS Section M (skin conditions) and Section K (nutrition)
- Physician, NP, and wound consult notes
- Hospital admission records describing the wound on arrival
- Facility skin and wound policy in effect at the time
Federal requirements experts apply
Tags from the CMS State Operations Manual Appendix PP, Rev. 232 (July 23, 2025), with the 42 CFR Part 483 citation. Whether a regulation establishes the standard of care is a question for your venue.
| Tag | Requirement | Citation |
|---|---|---|
| F686 | Treatment and services to prevent or heal pressure ulcers | 42 CFR 483.25(b)(1) |
| F684 | Quality of care | 42 CFR 483.25 |
| F692 | Nutrition and hydration status maintenance | 42 CFR 483.25(g) |
| F580 | Notify of changes | 42 CFR 483.10(g)(14) |
| F641 | Accuracy of assessments | 42 CFR 483.20(g) |
| F726 | Competent nursing staff | 42 CFR 483.35(a)(3) |
Appendix PP is revised periodically. Confirm the version in effect on the date of the incident.
What counsel should investigate
- Was the resident scored as at risk on admission, and did the interventions match that score?
- Do the repositioning records show real variation, or the same entries repeated?
- When the wound advanced a stage, how long until the physician and family were told?
- Was a dietitian involved once weight or intake dropped?
- Did the ordered support surface actually arrive, and is there a delivery or maintenance record?
- Does the facility's unavoidability argument address every element of F686, or only comorbidities?
Which expert fits
- Wound care certified nurse or nurse practitionerStaging, healing trajectory, treatment adequacy, and whether the wound was avoidable.
- Long-term care RN or Director of NursingAssessment, care planning, delivery of ordered interventions, and documentation standards.
- PhysicianCausation, comorbidity contribution, infection and sepsis sequelae, and end-of-life skin changes.
- Registered dietitianNutritional risk, protein and calorie adequacy, and the facility's response to weight loss.
How the other side usually argues it
Written for both sides. Plaintiff counsel should expect these; defense counsel will recognise them. Each answer is a records or regulatory point an expert can support.
The wound was clinically unavoidable.
F686 treats unavoidability as a sequence: evaluate, intervene, monitor, revise. The argument survives only if the chart shows every step.
This is skin failure at end of life, not a pressure injury.
It can be. It must be documented as such at the time, with the dying process recognised in the care plan, rather than relabeled after the fact.
It is moisture damage or an arterial ulcer.
Classification turns on location, wound bed, measurements and vascular history. A wound-certified expert resolves it from the photographs and records.
Panel members who work these cases
Matched from the ECS panel. Availability and conflicts are confirmed on the call.
Nancy L. Beecham
Director of Nursing, Registered nurse
Priti S. Gujar
Physician
Anne M. Harbord
Registered dietitian
For the paralegal handling this
Wound photographs and the TAR are the two items most often missing from a production. Ask for them by name, and ask for the mattress or support surface invoice. If the hospital staged the wound differently than the facility, flag that on the screening call.
Related case types
Dehydration and malnutrition
Weight loss, intake documentation, feeding assistance, and dietitian involvement.
See this case type ›Sepsis and infection
Change in condition, notification timing, delayed transfer, and infection control.
See this case type ›Understaffing
Staffing sufficiency, PBJ data, assignment sheets, and corporate budget decisions.
See this case type ›Twenty minutes on the care issues
Free screening with a nursing home expert.