Nursing Home Pressure Injury Litigation: What Attorneys Need From Medical Experts

Most of the mass tort work in this series involves a molecule, a device, or a platform, and a federal judge managing thousands of cases on one docket. Pressure injury litigation against skilled nursing and long term care facilities is the opposite. There is no MDL, no Judicial Panel centralization, no bellwether calendar. These cases are tried one resident at a time, in state court, under state negligence and elder abuse statutes, and they are won or lost on the facility’s own chart. That makes them the most expert dependent cases in the elder care space, and it is why plaintiff and defense counsel alike end up needing wound care nursing, long term care nursing administration, geriatric medicine, infectious disease, and, in death cases, forensic pathology.

The Litigation Landscape

The claim population is large and stable. A retrospective medicolegal study published in the International Wound Journal in April 2026 queried Westlaw for pressure injury malpractice cases litigated between 1990 and 2024 and identified 590 qualifying cases. Nursing homes were the most commonly named defendants at 59.8 percent, ahead of hospitals and outpatient surgical practices at 37.3 percent and individual physicians at 14.1 percent. Mean patient age was 71 years. The mean reported settlement was $383,099 against a mean jury award of $2,100,787, and adverse outcomes for providers were most strongly associated with allegations of inadequate care and gross negligence.¹

Two developments in 2026 matter to how these cases are now pleaded and defended, and counsel should be precise about what each one did and did not do.

First, the federal staffing floor is gone. CMS finalized minimum staffing standards for long term care facilities in May 2024, requiring 3.48 total nurse hours per resident day, 0.55 of those hours from a registered nurse, and a registered nurse onsite 24 hours a day. The U.S. District Court for the Northern District of Texas vacated the challenged provisions under 5 U.S.C. Section 706(2) in American Health Care Association v. Becerra, holding that the rule was not consistent with the statute Congress wrote, and the Northern District of Iowa reached a similar result.² Section 71111 of Public Law 119-21, signed July 4, 2025, barred federal spending to implement or enforce the standards through fiscal year 2034. CMS published an interim final rule on December 3, 2025, withdrawing the numerical standards and the 24 hour registered nurse requirement, effective February 2, 2026.³ The enhanced facility assessment process, which requires a facility to document how its staffing matches resident acuity, survives. For litigators the practical effect is that a plaintiff can no longer point to a federal numeric floor. Staffing adequacy now has to be proved through state minimums where they exist, the facility’s own assessment and policies, payroll based journal data, and expert testimony.

Second, corporate defendants continue to test how far liability travels up the ownership chain. In Newlin v. Vita Healthcare Group, 2026 Pa. Super. 175, decided August 4, 2026, the Pennsylvania Superior Court affirmed judgment notwithstanding the verdict for two management company defendants in a case alleging that a resident died as a result of an infected pressure ulcer. A jury had awarded $4,000,000 compensatory and $15,000,000 punitive damages across four defendants. The Superior Court confirmed a bright line rule that, where only the licensed healthcare provider has the contractual relationship with the resident, only that provider can be held liable on a corporate negligence theory, even where operations are delegated to a management company.⁴ That holding is Pennsylvania law, not national law, but it is a reminder that the medical proof has to stand on its own against the operator rather than resting on a corporate structure theory.

Verdicts in individual cases remain significant where the record supports them. On January 13, 2026, a Solano County, California jury returned a verdict in excess of $15,000,000 for the family of a 96 year old woman who developed sacral and buttock pressure ulcers during a short stay at a skilled nursing facility in 2019 and died months later, awarding $3,750,000 in compensatory damages and $12,000,000 in punitive damages on elder abuse and wrongful death claims.⁵ A central allegation in that case, and in many others, was that the wound was charted as a Stage 2 when photographs showed full thickness tissue loss. Those are case specific jury findings on the facts of that record. Every allegation in any other pending case remains an allegation to be proven.

The Injuries at Issue

Pressure injuries are staged under the revised National Pressure Ulcer Advisory Panel system published in 2016, which replaced the word ulcer with injury, moved to Arabic numerals, and separated deep tissue pressure injury and unstageable injury from the numbered stages.⁶ Stage 1 is intact skin with non blanchable erythema. Stage 2 is partial thickness skin loss with exposed dermis. Stage 3 is full thickness skin loss. Stage 4 is full thickness skin and tissue loss with exposed fascia, muscle, tendon, or bone. Deep tissue pressure injury presents as persistent non blanchable deep red, maroon, or purple discoloration over intact or non intact skin, and it is the stage most often mischaracterized in the chart.

The injuries that drive damages are the downstream ones: wound infection, cellulitis, osteomyelitis of the sacrum or ischium, bacteremia and sepsis, surgical debridement, flap reconstruction, colostomy or urinary diversion to protect a sacral wound, amputation where a heel injury progresses, months of intractable pain, and death. Secondary allegations usually travel with the wound: malnutrition and unintended weight loss, dehydration, failure to notify the physician or the family, failure to transfer, and inaccurate or altered documentation. The record is also where a punitive damages claim lives or dies, because a chart showing a wound frozen at Stage 2 across weeks of nursing notes while the resident deteriorates is the single most common evidentiary pattern in these cases.

The Science Behind the Claims

Two scientific questions decide most of these cases. Was the injury avoidable, and did it cause or contribute to the death.

On avoidability, the governing framework comes from the National Pressure Ulcer Advisory Panel consensus definitions, which CMS mirrors in the F686 surveyor guidance. A pressure injury is avoidable where the provider failed to evaluate the resident’s clinical condition and risk factors, failed to define and implement interventions consistent with recognized standards of practice, failed to monitor and evaluate the impact of those interventions, or failed to revise them as the resident’s condition changed. An injury is unavoidable where the provider did all of those things and the injury developed anyway.⁷ That framework is not a formality. It tells the expert exactly which four elements to walk through, and it is the structure a well built report should follow.

The prevention evidence base is the 2019 international clinical practice guideline from the European Pressure Ulcer Advisory Panel, the National Pressure Injury Advisory Panel, and the Pan Pacific Pressure Injury Alliance, which sets out 115 evidence based recommendations with graded strength of evidence.⁸ Counsel should note that the science has moved on one widely assumed point. In the TEAM-UP cluster randomized trial, nine nursing homes were assigned facility wide repositioning intervals of two, three, or four hours, with wearable sensors cueing staff. Among 992 evaluable residents with Braden scores of 10 or higher on high density foam mattresses, pressure injury incidence during the intervention was 0.0 percent against a 5.24 percent baseline, and repositioning compliance was highest in the four hour arm at 95 percent, compared with 90 percent at three hours and 80 percent at two hours.⁹ The authors concluded that two hour protocols can be relaxed for many nursing home residents on an appropriate support surface. An expert who testifies that a missed two hour turn is per se negligent, without engaging with risk stratification and support surface, is going to be impeached with that trial.

The epidemiology supplies the other half. CMS national averages published August 1, 2026 show 4.62 percent of long stay nursing home residents with pressure ulcers, reported total nurse staffing of 3.86 hours per resident day, nurse aide staffing of 2.32 hours, registered nurse staffing of 0.69 hours, total nursing staff turnover of 45.8 percent, and registered nurse turnover of 42.9 percent.¹⁰ Turnover near half the workforce is a fact pattern an expert can use, and state survey data lets counsel do the same at the individual facility level: F686 is the deficiency tag for pressure ulcer prevention and treatment, and repeat citations on the same tag across survey cycles support both notice and pattern. Prevalence data also cuts against easy assumptions. Analysis of the International Pressure Ulcer Prevalence survey covering 216,626 patients found that superficial injuries declined significantly from 2011 to 2016 while severe injuries, meaning Stage 3, Stage 4, unstageable, and deep tissue, did not decline at all.¹¹ A retrospective analysis of more than two million skilled nursing residents reported deep tissue pressure injury prevalence rising from 5.17 percent in 2019 to 7.16 percent in 2021 and stabilizing near 6.2 percent through 2023.¹²

Why Expert Witnesses Are Critical, by Specialty

Wound care certified registered nurses. The core liability witness. At least one state supreme court has squarely held that a registered nurse with wound care certification and long term care experience may give expert testimony on the nursing standard of care in the avoidance, treatment, and causation of pressure injuries, without a supporting physician opinion.¹³ This expert stages the wound from the photographs, reconciles the staging against the nursing notes, audits Braden scale scoring and reassessment frequency, evaluates the support surface, the turning and repositioning documentation, incontinence care, and heel offloading, and applies the avoidable versus unavoidable framework element by element.

Long term care nursing administration and staffing. With the federal floor withdrawn, this is now a separate expert role. It requires someone who can read payroll based journal data, the facility assessment, acuity and case mix, assignment sheets, and agency usage, and explain whether the staffing actually deployed on the relevant shifts could have delivered the care plan the facility itself wrote.

Geriatric medicine and internal medicine. Physician causation testimony on comorbidity, perfusion, end of life trajectory, and the defense theme that the wound was a marker of an irreversibly declining patient rather than a product of neglect. The same witness addresses physician notification, response to change in condition, and transfer decisions.

Infectious disease and wound surgery. Needed whenever the wound progressed to osteomyelitis, bacteremia, or sepsis, to connect the wound to the infection, to the hospitalization, and to the surgical course, including debridement and flap reconstruction.

Registered dietitians and nutrition experts. Malnutrition, hypoalbuminemia, and protein loss are both risk factors for injury development and barriers to healing, and nutritional assessment, supplementation, and weight loss monitoring are almost always pleaded alongside the wound.

Forensic pathology. In wrongful death cases the fight is whether the pressure injury caused or substantially contributed to death or was incidental to dementia, cardiac disease, or another terminal process. That is a cause of death opinion, and it needs a pathologist who will read the death certificate, the hospital record, and the autopsy where one exists.

Life care planning and economics. Where the resident survives with a chronic wound, ostomy, or amputation, the future cost of wound care, equipment, and attendant care has to be quantified.

Key Dates

How Med Legal Pro Helps

Pressure injury cases are decided by whether someone credible can stand in front of a jury, take the facility’s own chart apart, and explain in plain language what should have happened and when. Med Legal Pro places wound care certified nurses, long term care nursing administrators, geriatricians, infectious disease physicians, dietitians, forensic pathologists, and life care planners on both plaintiff and defense matters, runs a conflict check before any expert speaks with counsel, and puts every report through an internal review process before it reaches you. The Expert for Experts.

Sources

1. Pressure Injury Malpractice Litigation: A Retrospective Medicolegal Study, International Wound Journal, April 26, 2026. doi:10.1111/iwj.70923
2. American Health Care Association v. Becerra, No. 2:24-cv-00114 (N.D. Tex.), order vacating 42 C.F.R. Sections 483.35(b)(1) and 483.35(c).
3. Medicare and Medicaid Programs, withdrawal of minimum staffing standards for long term care facilities, interim final rule, 90 Fed. Reg., December 3, 2025, effective February 2, 2026. govinfo.gov
4. Newlin v. Vita Healthcare Group, No. J-A18034-25, 2026 Pa. Super. 175 (Pa. Super. Ct. Aug. 4, 2026).
5. California nursing home pressure ulcer verdict, Solano County, January 13, 2026, reported by Medical Malpractice Lawyers, March 13, 2026.
6. Edsberg LE, Black J, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. Journal of Wound, Ostomy and Continence Nursing. 2016;43(6):585-597. doi:10.1097/WON.0000000000000281
7. WOCN Society Position Paper: Avoidable versus Unavoidable Pressure Ulcers (Injuries), 2017, adopting the NPUAP consensus definitions. doi:10.1097/WON.0000000000000361
8. EPUAP, NPIAP and PPPIA. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, third edition, November 2019, 115 evidence based recommendations. epuap.org
9. Yap TL, Horn SD, Sharkey PD, et al. Effect of Varying Repositioning Frequency on Pressure Injury Prevention in Nursing Home Residents: TEAM-UP Trial Results. Advances in Skin and Wound Care. 2022. PMID 35051978
10. CMS Provider Data Catalog, Nursing Home State and US Averages, processing date August 1, 2026. data.cms.gov
11. Predictors of superficial and severe hospital acquired pressure injuries, International Pressure Ulcer Prevalence survey, 216,626 patients, 2011 to 2016.
12. A Retrospective Analysis of Deep Tissue Pressure Injury in Skilled Nursing Facilities, Advances in Skin and Wound Care, prevalence 2019 to 2023. doi:10.1097/ASW.0000000000000488
13. Gaines v. Comanche County Medical Hospital (Okla.), holding as a matter of first impression that a wound care certified registered nurse is qualified to give standard of care testimony on the avoidance, care, and cause of bedsores. oscn.net

Tracy L. Liberatore Esq, PA-Emeritus, Med Legal Pro. This article is general information for attorneys and is not legal or medical advice.