Never Event Hospital-acquired Pressure Injuries to the Skin: Discharge Without Disclosure
Dr. Greg Vigna
LOS ANGELES, CA, UNITED STATES, January 5, 2026 /EINPresswire.com/ -- “We are investigating multiple cases involving hospital discharges where 'Never Event' deep tissue pressure injuries are labeled as moisture-associated skin damage, without disclosure to the patient, their families, or the medical facility receiving the patient. In the medical profession, this practice is often referred to as a 'dump,'" said Greg Vigna, MD, JD, national pressure injury attorney.
What is a Never Event?
“Because Never Events are devastating and preventable, health care organizations are under increasing pressure to eliminate them completely. The Centers for Medicare and Medicaid Services (CMS) announced in August 2007 that Medicare would no longer pay for additional costs associated with many preventable errors, including those considered Never Events,” according to the Department of Health & Human Services.
Read about Never Events: https://psnet.ahrq.gov/primer/never-events
Dr. Greg Vigna, MD, JD, spinal cord injury physician, and national bedsore attorney states, “Hospitals know that patients who develop deep Stage III or Stage IV decubitus ulcers suffer serious injuries and require extended hospital-level care to prevent complications such as severe malnutrition, chronic osteomyelitis, and sepsis, while medically optimizing both the patient and the wound for reconstructive surgery. Hospitals know how to treat pressure injuries and have the medical staff and resources to do so. Hospitals also know they will not be reimbursed for the required care if the patient remains hospitalized. Hospitals know they employ nurses who document wounds as moisture-associated skin damage rather than pressure injuries. And hospitals know they have physicians who will write discharge orders to facilities that lack the capabilities to properly manage pressure injuries.”
Is it morally defensible to discharge a patient with a Stage IV pelvic decubitus ulcer with osteomyelitis without offering them curative care with flap closure?
“Among patients with decubitus-related osteomyelitis who did not undergo myocutaneous flapping, outcomes were generally poor regardless of treatment, and not significantly improved with prolonged antibiotics,” states Laura Damioli, MD.
Read Dr. Damioli’s article to learn more.
What does the Wound Healing Society's 2023 guideline update report regarding the necessity of curative care for pressure injuries?
“Guideline 6.8: A pressure ulcer should be closed surgically if it does not respond to wound care and there is no other contraindication to the surgical procedures. Exceptions may include the elderly or patients with a fatal illness, for whom palliative, local wound care is more appropriate. (Level I –increased).
Principle: Wound closure decreases protein loss, fluid loss, the possibility of wound infection, and the later development of malignancy in the wound. Early complication rates are acceptably low."
Read the WHS Guidelines: https://onlinelibrary.wiley.com/doi/full/10.1111/wrr.13130
Dr. Vigna states, “Patients with hospital-acquired Stage IV bedsores require ongoing acute hospitalization and early surgical debridement, clinitron bed support, medical optimization, wound preparation, and reconstructive surgery. Instead, across the country, these seriously injured patients are discharged to nursing homes, long-term acute care hospitals, or even a home with hospice, where a prolonged and difficult demise is foreseeable.”
Dr. Vigna concludes, “We represent individuals who have suffered hospital-acquired ‘Never Event’ pressure injuries, many of whom are not offered curative care, which is the standard of care, and many of whom are ‘dumped’ on lesser-equipped facilities with deep tissue injuries, where death is foreseeable.”
Greg Vigna, MD, JD, is a national malpractice attorney and an expert in wound care. He is available for legal consultation for families and patients who have suffered decubitus ulcers due to poor nursing care at hospitals, nursing homes, or assisted living facilities. The Vigna Law Group, along with Ben C. Martin, Esq., of the Ben Martin Law Group, a Dallas, Texas, national pharmaceutical injury law firm, jointly prosecutes hospital and nursing home neglect cases resulting in bedsores nationwide.
Read Dr. Vigna’s book regarding the standard of care for pressure injuries here.
Watch Dr Vigna’s episode Bed Sores: Caused by Ineffective Care
https://youtu.be/IrAwrErWUJo?si=3XdMK3DZAA50_y-k
Watch Dr Vigna’s episode Bed Sores: Never Events
https://youtu.be/5KS4IpbDD68?si=PDT0bncc4MmCWGDw
Click here to learn how to keep your family members safe from pressure injuries.
Greg Vigna, MD, JD
Vigna Law Group
+1 8178099023
email us here
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