This article is the fourth installment in our ongoing wound care series focused on pressure ulcers, nursing home negligence, and wound-related litigation. In this article, we examine what can happen when a resident is transferred between hospitals, nursing homes, rehabilitation facilities, physical therapy centers, and other long-term care providers, and why these transitions often become central issues in serious bedsore cases.
Why Bedsore Cases Can Be Difficult to Untangle
For many families, one of the most frustrating parts of these situations is trying to determine where a wound developed, when it worsened, and who was responsible for preventing or treating it.
Those answers are not always straightforward.
Why Transfers Can Increase the Risk of Pressure Ulcers
Elderly and medically fragile patients are often transferred multiple times during the course of their care.
A resident may move from a hospital to a rehabilitation center, from a rehabilitation facility to a nursing home, or from a nursing home back to a hospital after a change in their condition. Some patients are transferred repeatedly within a relatively short period of time. Each transfer creates another opportunity for important information to be missed, delayed, or misunderstood.
This is especially dangerous when a patient already has a pressure ulcer or is considered at a high risk for skin breakdown.
Residents who are immobile, malnourished, recovering from surgery, suffering from infection, or dependent on staff for repositioning are particularly vulnerable during transitions in care. Long transport times, delays in treatment, missed assessments, and inconsistent wound care can cause a pressure ulcer to worsen quickly.
In some situations, a wound that was relatively minor during one admission may become significantly more severe after transfer to another facility.
What Should Happen When a Patient is Transferred?
When a resident is transferred between healthcare facilities, important medical information is expected to follow the patient.
This includes information about existing wounds, skin condition, mobility limitations, nutritional concerns, infection risk, treatment plans, and physician orders.
In pressure ulcer cases, the transferring and receiving facilities should both be documenting the resident’s skin condition carefully. This often includes:
- Whether a wound was already present
- The location and stage of the pressure ulcer
- The size and appearance of the wound
- Signs of infection or deterioration
- Current wound care treatment orders
- Whether specialty mattresses, turning schedules, or other preventative measures are in place
The receiving facility is also generally expected to conduct its own skin assessment shortly after admission.
These evaluations can become critically important later if questions arise about whether a wound worsened before or after transfer.
Learn more about how pressure ulcers are staged
Why Communication Failures Matter
Pressure ulcer cases involving transfers often involve breakdowns in communication between providers.
A hospital may discharge a patient with wound care instructions that are never fully carried out after admission to a nursing home or rehabilitation facility. A receiving facility may fail to recognize how serious a wound already is. Important physician orders may not be communicated clearly to staff members responsible for daily care.
In some situations, the problem is not that information was unavailable. It is that the information was never properly relayed between departments, shifts, or facilities.
For example, a resident may arrive with instructions requiring repositioning every two hours, specialized wound dressings, nutritional supplementation, or close monitoring for infection. If those instructions are delayed, misunderstood, or inconsistently followed after transfer, the resident’s condition may deteriorate rapidly.
These communication failures can become especially dangerous when staffing shortages, high patient turnover, or inadequate training are already affecting the facility.
When Facilities Disagree About Where the Bedsore Developed
One of the most common issues in transfer-related wound cases is disagreement over when the pressure ulcer developed or worsened.
A hospital may claim the wound was already present when the patient arrived from a nursing home. A nursing home may argue the injury began during hospitalization. A rehabilitation center may document the wound differently than the facility that transferred the resident.
Families are often left caught in the middle of conflicting explanations.
In some cases, a wound may not have been documented at all during admission. In others, the staging of the wound may change significantly between records from different facilities.
These disputes matter because pressure ulcers can worsen quickly when proper prevention and treatment are delayed. Determining when the injury progressed may require careful review of medical records, wound assessments, photographs, staffing documentation, and treatment notes from multiple providers. In many cases, evaluating what occurred involves reconstructing the timeline of care across multiple admissions, transfers, and healthcare providers.
Why the First Days After Transfer Matter
The first hours and days after admission to a new facility are often critical in pressure ulcer cases.
A resident arriving from a hospital, rehabilitation center, or another nursing facility may already require aggressive wound monitoring and preventative care. If skin assessments are delayed, wound care orders are not implemented promptly, or repositioning schedules are interrupted during the transition, a pressure ulcer may worsen quickly.
In some cases, treatment that was ordered at one facility is not fully continued after transfer. Dressings may not be changed appropriately, pressure relief measures may not be in place, or signs of deterioration may not be escalated to a physician in a timely manner.
These breakdowns in continuity of care can become especially dangerous when a resident is already medically fragile or showing signs of infection.
The Importance of Documentation and Skin Assessments
Documentation often becomes one of the most important issues in transfer-related bedsore cases.
Healthcare providers are expected to maintain accurate records regarding a patient’s condition, treatment, and progression of wounds. In pressure ulcer cases, this documentation may include:
- Admission skin assessments
- Wound measurements
- Photographs
- Nursing notes
- Physician evaluations
- Wound care consultations
- Repositioning records
- Treatment orders
These records may later help establish whether a wound was identified promptly, whether it worsened over time, and whether appropriate treatment was provided.
Missing or inconsistent documentation can create serious concerns.
For example, one facility may describe a wound as a Stage 2 pressure ulcer while another later documents extensive tissue loss or signs of infection shortly after transfer. In some situations, families discover there are little or no records showing consistent wound monitoring at all.
Because pressure ulcers can change rapidly, accurate documentation is critical not only for patient care, but also for understanding what occurred during a resident’s treatment.
Can More Than One Facility Be Held Responsible?
Yes.
In some cases, responsibility may involve multiple healthcare providers or facilities.
One facility may fail to prevent the wound from developing, while another may fail to recognize signs of deterioration or provide appropriate treatment after transfer. A hospital may stabilize a patient medically but fail to communicate the severity of a pressure ulcer during discharge. A nursing home may then fail to continue necessary wound care interventions.
These cases are often more complicated than situations involving a single provider.
Determining responsibility may require reviewing care provided over weeks or months across multiple facilities, admissions, and transfers.
What families should know after a transfer
Families are often focused on the reason for the transfer itself, whether it involves surgery, rehabilitation, infection, or recovery from illness. During these transitions, pressure ulcers and skin breakdown may receive less attention until the condition becomes severe.
After a transfer, families may want to ask:
- Was a skin assessment completed upon admission?
- Did the resident already have a pressure ulcer?
- Has the wound changed or worsened since transfer?
- What wound care plan is currently in place?
- Is the resident being repositioned regularly?
- Are there signs of infection or declining condition?
- Has a wound care specialist been consulted?
Families should also pay attention to sudden declines in condition, increased confusion, fever, drainage, foul odor, or unexplained hospitalizations following transfer between facilities.
These situations may indicate that a wound has progressed significantly.
Questions About a Loved One’s Care?
Cases involving worsening bedsores after transfer between hospitals, nursing homes, rehabilitation centers, and long-term care facilities can be medically and legally complex. Our attorneys have experience handling pressure ulcer cases involving disputed timelines, communication failures, infection progression, and questions surrounding responsibility between providers.
If you have concerns about a loved one who developed a serious bedsore or experienced a decline after transfer between facilities, we encourage you to reach out. You can call us at 706-354-4000 or complete our online contact form. We offer free case evaluations, and there is no fee unless we recover money for you in your case.
In the final article in this series, we will examine catastrophic wound care outcomes, including amputation and wrongful death resulting from advanced pressure ulcers and related complications.
Related Posts
Bedsores in Nursing Homes: When Pressure Ulcers May Be a Sign of Neglect
Understanding the Braden Scale and Norton Scale in Nursing Homes
Understanding Medical Malpractice in Bedsore Cases
Infected Bedsores, Sepsis, and Osteomyelitis: When Wounds Become Life-Threatening
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