The 4 Stages of Bedsores: What Families Need to Know
If you've discovered that a loved one in a nursing home or hospital has developed bedsores, you're likely experiencing a range of difficult emotions — fear, confusion, guilt, and anger. You want to understand how serious the injury is, what treatment is needed, and whether someone failed to provide the care your family member deserved.
Understanding the stages of bedsores is one of the most important steps you can take right now. The stage of a bedsore tells you how deep the wound has progressed, what kind of medical intervention is required, and — in many cases — how long the injury has been developing without proper attention.
This guide walks you through each of the four stages of bedsores as classified by the National Pressure Injury Advisory Panel (NPIAP), along with two additional categories that medical professionals use. We'll explain what each stage looks like, how it's treated, what it means for your loved one's health, and when a bedsore may be evidence of nursing home negligence.
How Bedsores Are Classified
Bedsores — also called pressure ulcers, pressure injuries, or decubitus ulcers — are areas of damaged skin and tissue caused by sustained pressure that cuts off blood flow. They most commonly develop over bony prominences such as the tailbone, heels, hips, and shoulder blades, particularly in patients who are immobile or have limited ability to reposition themselves.
The NPIAP, the leading authority on pressure injury classification, uses a staging system based on the depth of tissue damage. The system includes four numbered stages plus two additional categories: unstageable pressure injuries and deep tissue pressure injuries. Understanding what bedsores are and what causes them can help you assess your loved one's situation more clearly.
It's important to note that pressure injuries don't always progress neatly from Stage 1 through Stage 4. A wound can develop rapidly into a severe stage, and healing does not occur in reverse order — a Stage 4 wound that improves does not become a Stage 3, then a Stage 2. Medical professionals describe healing wounds by their original worst stage.
Stage 1: Non-Blanchable Erythema of Intact Skin
What It Looks Like
A Stage 1 pressure injury is the earliest and mildest form. The skin remains intact, but a localized area shows persistent redness that does not turn white (blanch) when pressed. In individuals with darker skin tones, the discoloration may appear as a purple, blue, or dark patch rather than red. The affected area may also feel warmer, cooler, firmer, or softer than the surrounding skin.
Your loved one may report that the area is painful, itchy, or tender — though patients with reduced sensation may not feel anything at all, making visual inspection essential.
Treatment
Stage 1 bedsores are fully reversible with proper and prompt intervention. Treatment at this stage focuses on:
- Immediate pressure relief — repositioning the patient to remove all pressure from the affected area
- Pressure-redistributing surfaces — using specialized mattresses or cushions
- Skin protection — keeping the area clean, dry, and moisturized
- Nutritional support — ensuring adequate protein, calorie, and fluid intake to promote skin integrity
- Ongoing monitoring — conducting frequent skin assessments to track improvement or deterioration
With appropriate care, a Stage 1 pressure injury typically heals within a few days to several weeks.
What It Means
Stage 1 is a critical warning sign. It tells caregivers that the patient's skin is under dangerous pressure and that immediate action is needed. When nursing home or hospital staff identify and respond to Stage 1 bedsores properly, the wound should never progress further. The fact that a bedsore has advanced beyond Stage 1 often raises serious questions about the quality of care being provided.
Stage 2: Partial-Thickness Skin Loss
What It Looks Like
At Stage 2, the pressure injury has broken through the outer layer of skin (epidermis) and may extend into the underlying layer (dermis). The wound typically presents as a shallow, open ulcer with a pinkish-red wound bed. It may also appear as an intact or ruptured fluid-filled blister.
Importantly, Stage 2 pressure injuries do not involve slough (a yellowish dead tissue) or bruising — the presence of these features would suggest a deeper injury. The wound is painful and may be moist or weeping.
Treatment
Stage 2 bedsores require active wound care in addition to the preventive measures used for Stage 1:
- Wound cleansing — gently cleaning the wound with saline or appropriate solutions
- Moist wound dressings — applying hydrocolloid or foam dressings to maintain a healing environment
- Continued pressure offloading — ensuring no pressure reaches the wound area
- Pain management — addressing the patient's discomfort, which can be significant
- Infection monitoring — watching for signs of bacterial infection such as increased redness, warmth, swelling, or drainage
With proper treatment, Stage 2 pressure injuries generally heal within several weeks to a few months.
What It Means
A Stage 2 bedsore indicates that the problem has been developing for some time. The skin barrier has been compromised, creating a real risk of infection. When a patient in a care facility develops a Stage 2 wound, it suggests that earlier warning signs were either missed or inadequately addressed — both of which point to potential lapses in care.
Stage 3: Full-Thickness Skin Loss
What It Looks Like
Stage 3 represents a significant escalation in severity. The wound extends through the full thickness of the skin and into the subcutaneous fat tissue beneath it. The wound may appear as a deep crater and can have areas of undermining and tunneling — meaning the wound extends beneath the intact skin surface, creating pockets of damage that aren't immediately visible.
Bone, tendon, and muscle are not yet visible at this stage, though the depth of the wound can vary depending on the anatomical location. Areas with more subcutaneous fat (such as the buttocks) may show deeper craters, while wounds on areas with thin tissue coverage (such as the bridge of the nose or the ear) may appear relatively shallow despite being full-thickness injuries.
Slough (yellow dead tissue) may be present in the wound bed but does not obscure the full extent of tissue loss.
Treatment
Stage 3 bedsores are serious wounds that require comprehensive medical intervention:
- Debridement — surgical or mechanical removal of dead (necrotic) tissue to promote healing
- Advanced wound dressings — specialized dressings such as alginate, hydrofiber, or negative pressure wound therapy (wound VAC)
- Infection control — cultures may be taken, and antibiotics prescribed if infection is present or suspected
- Nutritional optimization — high-protein diets and nutritional supplements to support tissue repair
- Specialty consultation — involvement of wound care specialists and potentially surgical teams
- Complete pressure redistribution — use of advanced support surfaces and strict repositioning schedules
Even with optimal treatment, Stage 3 pressure injuries typically require one to four months to heal, and some take significantly longer. The risk of serious complications, including bone infection (osteomyelitis) and systemic infection (sepsis), increases substantially at this stage.
What It Means
The development of a Stage 3 bedsore in a care facility is a strong indicator of sustained neglect. These wounds do not appear overnight. They develop over days to weeks of inadequate repositioning, failed skin assessments, and insufficient wound management. A Stage 3 pressure injury tells a very clear story: someone was not doing their job.
Stage 4: Full-Thickness Skin and Tissue Loss
What It Looks Like
Stage 4 is the most severe classification of pressure injury. The wound extends through the skin and subcutaneous tissue, reaching into deep structures including muscle, tendon, and bone. These are devastating, crater-like wounds that may expose underlying anatomical structures directly.
Stage 4 wounds frequently exhibit:
- Visible bone, muscle, or tendon within the wound bed
- Extensive undermining and tunneling beneath surrounding tissue
- Slough or eschar (dark, crusty dead tissue) covering portions of the wound
- Foul odor from necrotic tissue or infection
- Significant drainage that may be purulent (containing pus)
The visual appearance of a Stage 4 bedsore is deeply distressing. These are large, deep, often foul-smelling wounds that cause tremendous suffering for the patient and anguish for their families.
Treatment
Stage 4 bedsores require aggressive, often multidisciplinary medical care:
- Surgical debridement — removal of all dead and infected tissue, sometimes requiring multiple procedures
- Reconstructive surgery — in some cases, skin flap or graft procedures to close the wound
- Negative pressure wound therapy — vacuum-assisted closure to promote healing from the wound base
- Intravenous antibiotics — to treat or prevent osteomyelitis, cellulitis, and sepsis
- Pain management — often requiring prescription pain medications
- Intensive nutritional support — sometimes including supplemental or parenteral nutrition
- Long-term wound management — daily or near-daily wound care for months
Healing times for Stage 4 pressure injuries range from several months to several years. Many patients, particularly elderly individuals with underlying health conditions, never fully recover. The complications associated with Stage 4 bedsores include osteomyelitis, sepsis, cellulitis, and squamous cell carcinoma — any of which can be fatal.
According to the Agency for Healthcare Research and Quality (AHRQ), more than 60,000 Americans die each year from complications related to pressure ulcers. Research published in peer-reviewed medical journals has found that patients with pressure injuries have approximately double the mortality risk compared to patients without them over a three-year period. For more information on the most severe cases, read our detailed guide on Stage 4 bedsore life expectancy.
What It Means
A Stage 4 bedsore represents a catastrophic failure of care. These wounds develop over an extended period of profound neglect — failed repositioning, ignored skin assessments, absent wound treatment, and systemic indifference to a patient's suffering. There is virtually no clinical scenario in which a Stage 4 bedsore in a care facility is considered acceptable or unavoidable with proper care protocols in place.
Additional Categories: Unstageable and Deep Tissue Pressure Injuries
Beyond the four numbered stages, the NPIAP recognizes two additional classifications:
Unstageable Pressure Injury
An unstageable pressure injury involves full-thickness skin and tissue loss in which the true depth of the wound cannot be determined because the wound bed is obscured by slough or eschar. Once the dead tissue is removed through debridement, the wound will reveal itself as either a Stage 3 or Stage 4 injury. Unstageable wounds are always serious and indicate advanced tissue damage.
Deep Tissue Pressure Injury (DTPI)
A deep tissue pressure injury presents as a localized area of persistent, non-blanchable deep red, maroon, or purple discoloration — or as an intact or ruptured blood-filled blister. This type of injury originates at the level of the muscle and bone, near the interface where the body presses against a surface, and works its way outward. DTPIs can evolve rapidly — within hours — into extensive Stage 3 or Stage 4 wounds, even with optimal treatment once discovered.
When Bedsores Indicate Negligence
Federal law requires nursing homes to prevent bedsores. Under the CMS regulation known as F686 (42 CFR §483.25(b)), facilities must ensure that residents who do not have pressure ulcers do not develop them — unless the clinical circumstances make them truly unavoidable.
This is a critical legal distinction: the burden is on the facility to prove the bedsore was unavoidable, not on the family to prove neglect occurred.
The accepted standards of care for bedsore prevention are well established:
- Repositioning immobile patients at least every two hours
- Conducting regular skin assessments during every shift
- Using pressure-relieving devices such as specialized mattresses and cushions
- Maintaining proper nutrition and hydration
- Managing incontinence promptly to prevent moisture-related skin damage
- Documenting all care in the patient's medical record
When a facility fails to follow these basic protocols and a bedsore develops — or when an early-stage wound is allowed to worsen — that constitutes negligence. The more advanced the stage of the bedsore, the stronger the evidence that care standards were not met over an extended period.
If you're wondering whether your family's situation may warrant legal action, our article on whether you can sue for bedsores addresses the key questions families typically have.
Bedsore Statistics That Every Family Should Know
The scope of the bedsore crisis in American healthcare facilities is staggering:
- Approximately 1 in 10 nursing home residents will develop a pressure injury during their stay (CDC)
- Prevalence rates in nursing homes range from 2% to 28% depending on the facility
- Up to 60,000 Americans die annually from pressure ulcer-related complications (AHRQ)
- The cost of treating a single bedsore ranges from $500 to $70,000, with the nation spending an estimated $11 billion per year on pressure ulcer care
- Pressure ulcers are substantially underreported in CMS nursing home quality ratings, according to a 2022 study in Medical Care
- A 2019 CUNY investigation found that nine of the ten nursing homes with the highest bedsore rates in New York State were in New York City
These are not obscure injuries affecting a handful of patients. Bedsores are a systemic epidemic of preventable harm — and families have the right to hold negligent facilities accountable.
What You Should Do If Your Loved One Has Bedsores
If you've identified bedsores on your loved one — at any stage — take these steps immediately:
- Document the wound. Take clear photographs with timestamps. Note the size, location, color, and any odor or drainage.
- Request medical records. Obtain your loved one's skin assessment logs, repositioning schedules, wound care notes, and nursing records.
- Ask questions. Ask the nursing staff when the wound was first identified, what stage it is, and what treatment plan is in place.
- Report the facility. File a complaint with the New York State Department of Health if you believe care standards were not met.
- Consult an experienced bedsore attorney. A lawyer who understands pressure ulcer negligence can evaluate the medical evidence, identify liable parties, and help your family pursue the compensation your loved one deserves.
For more information about potential compensation, visit our guide on average bedsore lawsuit settlements.
Talk to a New York Bedsore Lawyer — Free Case Evaluation
At Sinel & Olesen, PLLC, we represent families across New York City whose loved ones have suffered from bedsores caused by negligent care. We understand the pain and frustration of discovering that someone you love has been harmed in a facility you trusted — and we're here to help.
Every bedsore tells a story. The stage of the wound tells us how long the neglect lasted, how severe the failure of care was, and what your loved one endured. Our experienced bedsore lawyers will review the medical evidence, determine what went wrong, and fight to hold the responsible parties accountable.
There is no cost for your initial consultation, and you pay nothing unless we recover compensation for your family.
Call us today at 212-465-1000 or contact us online for a free, confidential case evaluation.
We're located at 330 7th Avenue, 10th Floor, New York, NY 10001.
The information on this page is for educational purposes and does not constitute legal advice. Every case is different. Contact our office to discuss your specific situation.
