Pressure Ulcers vs Deep Tissue Injury vs Blisters

Our law office has handled several Pressure Sore, Pressure Ulcer cases where the defense tries to categorize a pressure ulcer as a "deep tissue injury" which was hidden and not visible to caregivers thereby excusing the caregivers from observing and treating the wound. They usually contend  that the wound popped up out of nowhere suddenly and in an advanced stage. In other words this wound was unpreventable and untreatable in its earlier stages because it was hidden under the surface of the skin. This defense distorts the definitions and progression of each type of wound.  Usually the actual progression of most skin disorders I have handled were in fact pressure ulcers and not hidden "deep tissue Inujury". Mischaracterizing a pressure ulcer as a deep tissue injury is usually an attempt to skirt the mandate of federal regulations regarding the prevention of bed sores. They are seperate and distinct skin wounds.

483.25(c) Quality of Care - Pressure Sores (also called Tag F314):
"Based on the Comprehensive Assessment of a resident, the facility must ensure that-
(1) A resident who enters the facility without pressure sores does not develop
pressure sores unless the individual’s clinical condition demonstrates that they were
unavoidable; and (2) A resident having pressure sores receives necessary treatment and services
to promote healing, prevent infection and prevent new sores from developing."

The National Pressure Ulcer Advisory Panel in 2007 redefined the definition of a pressure ulcer and
the stages of pressure ulcers, including the original 4 stages and adding 2 stages on deep tissue
injury and 1 on unstageable pressure ulcers.
A Pressure sore is defined in 2007 by the National Pressure Ulcer Advisory Panel (NPUA) as a
"A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony
prominence, as a result of pressure, or pressure in combination with shear and/or friction."
Pressure ulcers develop when capillaries supplying the skin are compressed enough to impede perfusion, leading ultimately to tissue necrosis. Without pressure over a bony prominence you don't have a pressure sore.

NPUA stated in 1998 that a Stage I pressure ulcer is an observable pressure related alteration of intact skin with indicators, as compared to an adjacent or opposite area on the body, which may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.  A pressure sore is visible or it is not a pressure ulcer by the 1998  definition.

A "Deep Tissue Injury", by contrast is defined in 2007 by NPUA as "Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear." The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Note the distinction created by these definitions when examining a stage 2 pressure ulcer versus a "deep tissue injury":  A stage 2 pressure ulcer: "Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation." Note that NPUA indicates that *Bruising indicates suspected deep tissue injury.
Note also that Stage 2 pressure ulcers can appear as "blisters" but they are indeed stage 2 pressure ulcers not common or benign blisters.
 
The Hamill Law Group has 34 years experience advocating for injured people including those who have suffered from nursing home neglect, abuse or wrongful death. The Hamill firm represents elders victimized by criminal assaults,  pressure sores , falls , sepsis and malnutrition.  For more information contact the Hamill group at (617) 479-4300 or use the law firm contact form.

See update to Pressure Ulcers vs Deep Tissue Injury vs Blisters