When Wounds Raise Concerns: A Guide for APS Professionals

By Kathleen Thimsen DNP, MSN, WOCN/CETN, FNS, DF-AFN, AFN-BC

August 2026

Adult protective services (APS) professionals frequently encounter reports involving skin changes, wounds, or soft tissue injuries that may raise concerns about neglect, maltreatment, or unmet care needs. However, a wound alone does not indicate that maltreatment occurred. APS assessments benefit from a comprehensive, evidence-based review of the person’s condition, care environment, documentation, treatment history, and other factors needed to understand how and why the wound developed.

For APS professionals, wound concerns are not simply observations. They can be indicators of possible abuse, neglect, self-neglect, exploitation, inadequate care planning, or unmet service needs. This brief discussion is intended to help APS staff recognize what information to request, what documentation to review, and when consultation with healthcare professionals may be needed to support a thorough and objective assessment. 

Standards of Care 

APS staff should use or refer to a healthcare professional to inform questions and observations and not make clinical diagnoses. Key items for collateral documentation include: 

• Completion of a skin assessment document
• Completion of risk tools to evaluate the potential for pressure injury, falls, nutrition and hydration, continence, and mobility
• Recorded risk-associated interventions were noted and updated as the person’s condition changed
• Timely report of concerns to medical providers
• Explanations regarding additional interventions or safeguards were established to prevent worsening or to support and encourage healing

Across care settings, including private homes, nursing homes, skilled nursing facilities, rehabilitation centers, and hospitals, standards of care require that individuals receiving care should have a documented, comprehensive skin assessment upon admission. This assessment should include a full-body review and identification of skin alterations, with notation of a comprehensive wound assessment that includes wound location, size, tissue type, amount of predominant tissue, wound edges and margins, exudate type and amount, and odor. Wound photographs at the time of admission are also within a standard of care today.

 
Risk assessments, used to identify individual risks for common care-related injury and harm, should include documentation noting the potential risk for skin breakdown, falls, and nutritional concerns. The risk assessments should have guided caregivers to risk-specific interventions to be implemented as a response to the varied potentials. The risks and interventions should be noted in the record in nursing documentation and care planning and be reflected in provider orders to ensure closed-loop communication. For APS, missing screenings or assessments may signal the need for follow-up, especially when a wound, change in condition, or unmet prevention or treatment need is present. Identifying the gaps across the care process (screening at admission through provider orders and routine documentation) may inform the quality issues and aid APS staff in providing a remediation pathway aligned with best practices through a consultative communication process.

Standard practice calls for routine documentation of the person’s physical condition and any skin or wound changes, including all areas of breakdown. These findings should be recorded in the medical record and care plan when applicable. Wound documentation typically includes each wound’s comprehensive assessment parameters as they can provide valuable information on the current status of the wound and insight on progress. 

APS staff should look for consistent documentation of wound assessments in the record, associated documentation of skin and wound treatments, change in status, corresponding interventions employed to address risks or treatment orders, nutrition and hydration status, all supportive measures aimed at reducing pressure, and shear/friction on high-risk areas of the body. Additionally, all patient and family education along with referral information should be documented in the medical record. This gives all care providers and APS staff a picture of the continuity of care and comprehensive standards followed to promote safe and effective care of the adult. Gaps, contradictions, or unexplained changes in these records can help APS identify issues that need further inquiry.

The risk assessments for skin breakdown and falls have been a standard of care for decades. For APS professionals, the absence of a documented risk assessment may be an important reason to ask additional questions about whether risks were identified and appropriately addressed. The standardized tool used in most healthcare organizations is the Braden Tool. This is a validated instrument for identifying an individual’s risk for skin breakdown. It uses a score from six to 23 to show the level of risk:

• 19–23: no risk
• 15–18: low risk
• 13–14: moderate risk
• 10–12: high risk
• 9 or less: severe risk

APS professionals do not need to administer or interpret the Braden Scale themselves; rather, its presence in the record can help APS understand whether risk was assessed and what interventions may have been indicated. Any deviation from these scoring parameters should be questioned, as the Braden Tool was designed and validated in research using these specified scores. Other scoring conventions have not been validated, and their use may result in negative outcomes.

Importantly, the presence of a wound does not by itself indicate maltreatment. Skin changes and alterations in older adults have varied causes and mechanisms of injury.  When reviewing the circumstances surrounding a wound, APS professionals should be aware of common causes of skin breakdown, including pressure, shear, and moisture-related injuries. Infectious causes of skin alterations often are mistaken as pressure injuries or may occur simultaneously with wounds. This occurs most often when appropriate or thorough hygiene is lacking. Infection may also be influenced by hygiene, underlying health conditions, or other factors. Additionally, skin alterations may be more likely among individuals with weakened immune systems or poor nutritional status.

Burns are another type of injury APS professionals may encounter when working with older adults. Accidental spills of hot liquid, exposure to heating pads, cigarettes, irons, or other heat sources may cause burns. Some burns may have a patterned appearance or circumstances that raise questions about their cause. APS should document what is observed and the explanation provided and, when appropriate, seek medical or forensic expertise rather than attempting to determine the cause of the burn independently.

For APS professionals, awareness of these medical possibilities is important because even a severe or rapidly deteriorating wound does not, by itself, establish neglect. Medical and/or forensic consultation may be necessary to understand whether the wound is consistent with the individual's condition and the care provided.

Regardless of what caused the skin changes and breakdown, all wounds should be assessed routinely by a healthcare professional and documented using narrative and notes, wound flow sheets, measurements, and when appropriate, photographs.

These records can be valuable sources of information during an APS investigation. Reviewing documentation over time may help APS understand when a wound developed, whether it improved or deteriorated, what interventions were provided, and how caregivers or healthcare professionals responded to changes in the individual's condition.

Today, healthcare professionals across all care settings and delivery sites have access to the most up-to-date standards of care. Most specialty organizations also provide practice guidelines and protocols for skin alterations, incontinence, and medical device-related skin breakdown and end-of-life wounds. Guidance addressing “avoidable vs. unavoidable” wounds may be especially valuable when APS is evaluating whether appropriate prevention and care occurred. 

APS professionals are not expected to become wound-care experts. Their role is to recognize concerns, document observations, gather relevant records and information, ask informed questions, and seek medical or forensic consultation when necessary. Looking beyond the wound itself and considering the adult's health, functional abilities, identified risks, care needs, environment, and the care actually provided can help APS make a more-informed assessment of whether maltreatment may have occurred.

APS professionals are not expected to become wound-care experts. Their role is to recognize concerns, document observations, gather relevant records and information, ask informed questions, and seek medical or forensic consultation when necessary. Looking beyond the wound itself and considering the adult's health, functional abilities, identified risks, care needs, environment, and the care actually provided can help APS make a more-informed assessment of whether maltreatment may have occurred.

Some useful resources can be found by visiting the following websites:

• Agency for Healthcare Research & Quality
• National Pressure Injury Advisory Panel  
• Wound, Ostomy, and Continence Nurses Society
  
  
  
   

The APS Blog is updated regularly with posts from contributing authors and new publications from the APS TARC.

How did we do? Take our quick customer satisfaction survey to give us feedback.

This publication was created by the Adult Protective Services Technical Assistance Resource Center (APS TARC) administered by the WRMA, Inc. under Contract No. 140D0424F1178 from the U.S. Department of Health and Human Services, Administration for Community Living, Administration on Aging. The views expressed in this publication do not necessarily reflect the views or policies of the Administration for Community Living or the U.S. Department of Health and Human Services.