Bedsore Treatment: What Proper Wound Care Looks Like

Your loved one has a bedsore. You ask the nursing home what they are doing about it. You get vague answers: “We’re keeping an eye on it.” “The wound care nurse visits weekly.” But the wound is not getting smaller. It may be getting worse. A meta-analysis found that negative pressure wound therapy heals 61.45 percent of advanced wounds, compared to only 36.90 percent with standard care [PubMed 31834011]. Proper treatment works. The question is whether the nursing home is providing it.

Proper bed sore treatment requires a documented plan that includes repositioning, wound care, nutrition, and monitoring. If your loved one’s nursing home is not providing this, a free case evaluation can help.

Find Out If Treatment Was Adequate

How Bedsores Should Be Treated

The 2019 NPIAP/EPUAP/PPPIA international guideline endorses the TIME framework for wound care. TIME stands for Tissue, Infection/Inflammation, Moisture, and Epithelial edge [NPIAP 2019 / PMC7523261]. Each domain requires a specific response.

This is the standard of care. A nursing home that is not following this framework may not be meeting its legal obligations.

Tissue: Removing Dead Tissue (Debridement)

Debridement is the first active treatment step for stage 2 wounds with dead tissue and all Stage 3 and Stage 4 injuries. Dead tissue blocks healing, supports bacteria, and hides how deep the wound really is [NPIAP 2019].

There are several debridement methods:

• Sharp debridement uses scalpels or curettes to cut away dead tissue. It is the most direct method for controlling bacterial buildup (biofilm) [NPIAP 2019].
• Autolytic debridement uses moisture-retentive dressings – hydrocolloids, hydrogels, or alginates – that let the body’s own enzymes break down dead tissue [NPIAP 2019].
• Biosurgical debridement uses sterile medical-grade larvae (maggot therapy) when other methods are unsafe. The larvae dissolve only dead tissue while their secretions fight bacteria.

The care plan should document which method was chosen and why. If debridement is needed but not being done, the wound cannot heal.

Infection: Controlling Bacteria

All chronic wounds carry bacteria. The clinical question is whether the bacterial load has crossed from normal colonization to active infection [NPIAP 2019].

Lightly colonized wounds may respond to topical antimicrobials. Cellulitis – spreading redness, warmth, swelling, and tenderness around the wound – requires systemic antibiotics.

When infection is accompanied by signs like high fever, rapid heart rate, and confusion, it may meet the threshold for sepsis. Sepsis is a medical emergency.

Osteomyelitis occurs when infection reaches bone. This happens most often in Stage 4 wounds. Treatment requires antibiotics for two weeks for cortical (outer) bone, or four to six weeks for medullary (inner) bone. Common organisms include Staphylococcus aureus, gram-negative rods, or Bacteroides fragilis [NPIAP 2019].

Moisture: Keeping the Wound Bed Balanced

Wounds heal most effectively in a moist – not wet, not dry – environment. The right wound dressing maintains this balance. Dressings must be changed regularly and matched to the wound’s drainage level.

Too much moisture causes maceration (softening of surrounding skin). Too little causes the wound bed to dry out and die.

Epithelial Edge: Monitoring Healing

The wound edges should be advancing inward. If they are not, something in the treatment plan is failing. The nursing home should be measuring the wound at regular intervals and documenting whether it is getting smaller.

Rolled wound edges (epibole) or wound edges that pull away from the wound bed are signs that the wound is stalling or worsening.

Negative Pressure Wound Therapy (NPWT)

For Stage 3 and Stage 4 bed sores, negative pressure wound therapy (NPWT) is one of the most effective treatments available. NPWT applies controlled suction to a sealed wound through a foam dressing. It removes excess fluid, reduces swelling, and promotes new tissue growth.

Meta-analysis data show a 61.45 percent healing rate with NPWT, compared to 36.90 percent with standard care for Stage 3 and 4 injuries. NPWT also heals wounds approximately 16.47 days faster [PubMed 31834011].

If a nursing home resident has an advanced pressure injury and NPWT has not been considered, ask why.

Nutrition and Bedsore Healing

Wound healing requires fuel. The NPIAP guideline recommends 1.25 to 1.5 grams of protein per kilogram of body weight per day for residents with active pressure injuries [NPIAP 2019].

Without adequate protein, the body cannot build new tissue to close the wound. Residents who are malnourished when they develop a bedsore face a much harder path to recovery.

The nursing home’s care plan should include nutritional targets, regular weight monitoring, and documentation of dietary intake. If your loved one is losing weight while having an active wound, the treatment plan is incomplete.

Treatment by Stage

What proper treatment looks like depends on the stage of the wound:

• Stage 1: Remove pressure immediately (offloading). Use a pressure-redistribution mattress. Reposition on schedule. Monitor daily. Most Stage 1 injuries resolve within 7 to 14 days with prompt action.
• Stage 2: Keep the wound bed moist with appropriate dressings. Mild debridement if needed. Protect from friction. Increase protein intake. Median healing time is 46 days.
• Stage 3: Active debridement, advanced wound dressings, NPWT, nutritional supplementation including protein targets, and regular wound measurement. Healing rate at six months is about 50 percent.
• Stage 4: Aggressive wound care including surgical debridement. NPWT strongly indicated. Surgical reconstruction (flap surgery) may be necessary. Only 5 percent of Stage 4 wounds close within eight weeks under conservative care.

For a full overview of all stages, see our Bedsore Stages Guide.

Repositioning and Support Surfaces

Repositioning is not just prevention. It is treatment. A resident with an active bedsore must be repositioned to keep pressure off the wound.

Standard practice calls for repositioning bed-bound residents every two hours. Research shows that turning every four hours on a viscoelastic foam mattress results in fewer pressure injuries than turning every two hours on a standard mattress [PMC7265629]. The right mattress makes a measurable difference.

Wheelchair-bound residents should shift weight every 15 minutes or be assisted with repositioning at regular intervals.

If the nursing home is using a standard mattress on a resident with an active wound, ask whether a pressure-redistribution surface has been considered.

When Treatment Failure Indicates Neglect

Not every wound that fails to heal indicates neglect. Some wounds are difficult to treat, especially in patients with multiple medical conditions. But if the nursing home cannot show that it provided evidence-based treatment, the failure may be more than clinical.

A treatment plan that does not include debridement rationale, protein targets, a repositioning schedule, wound measurement records, and dressing change documentation does not meet the federal standard of care [42 CFR 483.25(b)].

CMS reports pressure injury data on Nursing Home Care Compare. The facility-level range spans from 0 percent to 20 percent prevalence [CMS Care Compare]. That gap reflects real differences in care quality. Families can check their facility’s reported rate on the CMS website before and after a wound develops.