Stage 4 Pressure Ulcer

What Is a Stage 4 Pressure Ulcer?

A Stage 4 pressure ulcer is defined by the National Pressure Injury Advisory Panel (NPIAP) as full thickness tissue loss with exposed bone, tendon, or muscle. The wound extends through the epidermis, dermis, and subcutaneous fat, and has destroyed the fascia (connective tissue) that normally protects underlying structures.

Unlike earlier stages where the wound is relatively superficial, Stage 4 wounds create deep craters in the body. Slough (yellow fibrous tissue) or eschar (black dead tissue) may be present but does not obscure the depth of tissue loss. The wound bed may contain granulation tissue, undermining, and tunneling.

The depth of Stage 4 wounds varies by anatomical location. Wounds on areas with thin tissue layers (bridge of the nose, ear, ankle) may be shallow yet still classified as Stage 4 if bone or tendon is visible. Wounds over the sacrum or hip can be extremely deep, sometimes extending several inches into the body.

Extreme Severity of Stage 4 Wounds

Stage 4 pressure ulcers are among the most serious wounds a patient can develop. Their severity cannot be overstated:

Tissue Destruction

• Complete loss of all skin layers
• Destruction of subcutaneous fat tissue
• Damage to or exposure of muscle, tendon, or bone
• Possible undermining (tissue destruction beneath intact skin edges)
• Possible tunneling (channels extending from the wound into surrounding tissue)

Pain and Suffering

Stage 4 wounds cause extreme pain. The exposed deep tissues are highly sensitive, and patients experience significant discomfort during wound care, dressing changes, and even routine repositioning. Many patients require strong pain medication to manage their symptoms.

Healing Challenges

Stage 4 pressure ulcers may take months to years to heal, if they heal at all. Many patients with Stage 4 wounds require:

• Surgical debridement to remove dead tissue
• Skin grafts or flap surgery
• Vacuum-assisted wound closure (wound VAC therapy)
• Long-term intravenous antibiotics for bone infection
• Extended hospitalization or specialized wound care facilities

Even with aggressive treatment, some Stage 4 wounds never fully close, leaving patients with chronic, draining wounds for the rest of their lives.

Life-Threatening Complications

Stage 4 pressure ulcers carry an extremely high risk of serious, often fatal, complications:

Osteomyelitis (Bone Infection)

When bone is exposed in a Stage 4 wound, bacteria can directly infect the bone, causing osteomyelitis. This serious condition requires weeks to months of intravenous antibiotics and often surgical removal of infected bone. Osteomyelitis can become chronic and may necessitate amputation in severe cases.

Sepsis

Sepsis occurs when bacteria from an infected wound enter the bloodstream and trigger a body-wide inflammatory response. Stage 4 wounds provide a direct pathway for bacteria to enter the body. Sepsis is a medical emergency with mortality rates of 25-50% even with aggressive treatment. Many bedsore deaths are caused by sepsis.

Gangrene and Necrosis

The dead tissue in and around Stage 4 wounds can spread, leading to gangrene. This tissue death can become gas gangrene (a rapidly spreading, often fatal infection) or wet gangrene that continues to destroy surrounding healthy tissue. Amputation may be necessary to save the patient's life.

Death

Stage 4 pressure ulcers carry significant mortality risk. Studies show mortality rates of 25-33% within one year of developing a Stage 4 wound. Death typically results from sepsis, overwhelming infection, or complications of the underlying conditions that contributed to the wound's development.

Indication of Prolonged Neglect

Stage 4 pressure ulcers do not develop suddenly. They represent the end stage of a progression that typically takes weeks to months of continuous pressure, inadequate care, and ignored warning signs:

• Stage 1: Intact skin with non-blanchable redness (typically 1-2 days of unrelieved pressure)
• Stage 2: Partial thickness skin loss, blistering (days to a week of continued pressure)
• Stage 3: Full thickness skin loss exposing fat (weeks of inadequate wound care)
• Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle (prolonged failure of prevention and treatment)

For a wound to reach Stage 4, healthcare providers must have failed at multiple points: initial skin assessment, ongoing monitoring, pressure relief, nutritional support, wound treatment, and intervention as the wound progressed through earlier stages. Each stage represents an opportunity to prevent further deterioration—opportunities that were missed.

While some patients with severe underlying conditions may develop pressure injuries despite appropriate care, Stage 4 wounds in nursing homes and hospitals almost always indicate systemic care failures.

Legal Accountability for Stage 4 Wounds

Healthcare facilities have a legal duty to prevent and treat pressure ulcers. When Stage 4 wounds develop, facilities may be liable for:

Negligence

To establish negligence, a plaintiff must show that the facility owed a duty of care, breached that duty, and caused harm as a result. Stage 4 pressure ulcers often demonstrate clear breaches of duty:

• Failure to conduct adequate skin assessments
• Failure to implement turning and repositioning protocols
• Failure to provide appropriate support surfaces
• Failure to address nutritional deficiencies
• Failure to treat wounds at earlier stages
• Failure to notify families of worsening conditions
• Understaffing that prevents adequate patient care

Regulations Violated

Nursing homes receiving Medicare or Medicaid funding must comply with federal regulations (42 CFR §483) that require facilities to ensure residents do not develop preventable pressure ulcers. Development of a Stage 4 wound is often evidence that these regulations were violated.

Damages Recoverable

Victims of Stage 4 pressure ulcer negligence may recover compensation for:

• Medical expenses (hospitalization, surgery, wound care)
• Pain and suffering
• Permanent disfigurement and scarring
• Reduced quality of life
• Emotional distress
• Wrongful death damages (if the wound contributed to death)
• Punitive damages in cases of gross negligence or reckless conduct

Warning Signs Before Stage 4

Family members should be alert to signs that a loved one may be at risk for or developing serious pressure injuries:

• Any redness or skin changes over bony prominences
• Complaints of pain in pressure areas
• Open wounds or blisters
• Foul odor from wounds
• Fever or signs of infection
• Inadequate repositioning during visits
• Soiled bedding or incontinence products not being changed
• Weight loss or signs of malnutrition
• Staff seeming overwhelmed or unavailable

If you observe any of these warning signs, document them and address your concerns with facility management immediately. Request copies of your loved one's care records.

Documenting Stage 4 Pressure Ulcers

If your loved one has developed a Stage 4 pressure ulcer, thorough documentation is crucial for any potential legal action:

1. Photograph the wound with timestamps, including measurements and surrounding tissue (if facility allows)
2. Request complete medical records including wound care logs, nursing notes, physician orders, and incident reports
3. Document the timeline of when the wound was first noticed vs. when you were informed
4. Record all communications with staff about the wound and its treatment
5. Note staffing levels and any observations about care quality during your visits
6. Keep a journal of your loved one's condition, pain levels, and treatments at each visit
7. Obtain names and contact information for any witnesses to care deficiencies

When to Seek Legal Help

If your loved one has developed a Stage 4 pressure ulcer in a nursing home, hospital, or other care facility, you should consult a bedsore attorney if:

• The wound developed after admission to the facility
• The wound progressed from an earlier stage despite being documented
• Your family member has died or is critically ill from wound complications
• You were not promptly informed about the wound's development or progression
• You have concerns about the facility's staffing or care quality
• The facility is not providing adequate treatment for the wound
• Your loved one is suffering significant pain and distress

At Traction Law Group, we understand that Stage 4 pressure ulcers represent a devastating failure of care. We help families investigate how these wounds developed, hold negligent facilities accountable, and recover compensation for the suffering caused. There is no fee unless we win your case.

Wrongful Death from Stage 4 Bedsores

Tragically, Stage 4 pressure ulcers contribute to many deaths in nursing homes and hospitals each year. If your loved one died from complications of a Stage 4 bedsore—whether from sepsis, infection, or other complications—you may have a wrongful death claim.

Wrongful death claims allow surviving family members to recover compensation for funeral expenses, medical bills, loss of companionship, and the pain and suffering the victim experienced before death. These cases also serve an important purpose in holding negligent facilities accountable and potentially preventing similar tragedies from happening to other families.