OBJECTIVE: To evaluate the impact of in-hospital pressure ulcer development on mortality among older, high-risk, hospitalized patients up to 1 year post-hospital discharge, after adjusting for baseline patient characteristics, disease severity, hospital complications, and discharge activity level. DESIGN: A prospective, inception, cohort study. SETTING: An urban, tertiary, acute care, university teaching hospital. PATIENTS: A total of 286 patients aged 55 or older, expected to be confined to bed or chair for at least 5 days, who were admitted to the hospital without a Stage 2 or greater pressure ulcer. MEASUREMENTS: The primary outcome measurement was time to death from admission to 1-year post-hospital discharge. Baseline information included demographic, medical, functional, and nutritional variables known to be associated with increased mortality. Measures of global disease severity and co-morbidity included the admitting physician's estimate of illness severity and life expectancy, the acute physiology score of APACHE II, the Co-morbidity Damage Index, and the Medicus Nursing Classification Score. Baseline infections, incident infections, and noninfectious hospital complications were determined. Functional activity level was determined at hospital discharge. Post-discharge vital status was determined by telephone interviews at 3, 6, 9, and 12 months after discharge and confirmed by death certificate review. MAIN RESULTS: Development of an in-hospital pressure ulcer was associated with greater risk of death at 1 year (59.5% vs 38.2%, P = .02). However, pressure ulcer development did not remain independently associated with decreased survival after adjusting for other predictors of mortality. Predictors of mortality at hospital admission by multivariate Cox regression analysis included weight loss in the 6 months before admission (RR 2.4, CI 1.6,3.6), physician estimate of life expectancy (RR 2.1, CI 1.7,2.6), and the Co-morbidity Damage Index (RR 1.1, CI 1.0,1.2). Multivariate predictors of 1-year mortality at discharge included physician estimate of life expectancy (RR 2.2, CI 1.8,2.6), weight loss in the 6 months before admission (RR 2.2, CI 1.5,3.2), remaining confined to bed or chair (RR 1.9, CI 1.2,3.1), and the total number of hospital complications (RR 1.3, CI 1.2,1.5). CONCLUSIONS: Pressure ulcers that develop during acute hospitalization are not associated with reduced 1-year survival among high risk older persons after adjusting for nutritional and functional status, global measures of disease severity and co-morbidity, and noninfectious hospital complications.