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n the last issue of ECPN, I discussed the importance of having systems in place that assist the director of nursing (DON) in monitoring and managing specific care issues. Often, the DON realizes that the system for monitoring and managing one care area may overlap with systems utilized to monitor and manage other care areas. Such is the case when monitoring and managing pressure ulcer prevention and development in the nursing home.
       Despite the numerous resources available and the emphasis placed on pressure ulcer outcomes, many nursing facilities lack systems that ensure appropriate monitoring and managing of pressure ulcers.
       A good place to start in reviewing your current systems for monitoring pressure ulcers is the Federal Regulations. Section F314 of the Federal Regulations states, “Based on the comprehensive assessment of a resident, the facility must ensure that 1) a resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable and 2) a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.”
       If I asked your DON how she monitors pressures ulcers or other skin problems in the facility, how would she respond to the following questions?
1. What is done in relation to skin assessment on admission and discharge?
2. How is the clinical condition of the resident assessed for factors that may impact the potential for pressure ulcer development or healing?
3. How and when are risk assessments completed to identify residents at risk for development of pressure ulcers?
4. How are wounds in the facility routinely assessed and monitored for healing progress? How is this assessment documented in the medical record and reported to the appropriate staff members?
5. How are all residents routinely monitored for new skin problems?
6. What is done when a new skin area is identified?
7. Are staff members notified in a timely manner of new pressure ulcers?
8. What is your system for initiating immediate treatment and for notification of family or responsible parties of new pressure ulcers or worsening pressure ulcers?
9. How are the nutritional needs and/or risk factors identified for residents who are at risk or who have pressure ulcers?
10. When is pain assessed or addressed in the care of a resident with a pressure ulcer?
11. How is the plan of care reviewed and kept current for residents who are at risk and/or who develop new areas?
12. What education is included for the staff and how is wound care covered in orientation?
13. What quality assurance processes are in place to ensure all necessary components for healing and prevention and residents’ rights are being followed?
       These are the type of questions I ask staff whenever I am consulting with a facility that has requested I review their systems on pressure ulcers. Quite often, when a facility has deficiencies cited regarding pressure ulcers, they are unsure of their facility’s procedure or do not have a system in place for addressing the above items.
       When considering these areas, it is a good idea to look at the quality indicator links that are associated with skin care. These links are new fractures, bladder/bowel incontinence, indwelling catheters, weight loss, dehydration, bedfast residents, and daily physical restraints.
       In addition, pressure ulcers are also linked with the domains of infection control—urinary tract infection, elimination/incontinence, nutrition/eating, physical functioning, and quality of life for the Minimum Data Set (MDS)-based quality indicator domains.
       At a minimum, if I were a DON, I would want systems in place to ensure the following to assist me in monitoring and managing pressure ulcers:
• During an admission or pre-admission conference with the resident or his or her responsible party, question the activity of the resident in the weeks prior to admission and include this information with your admission assessment. Often, residents have been bedfast or had extensive time in surgery, which could contribute to possible deep tissue injury and could cause a predeveloping ulcer that may not be readily recognized on assessment of the skin on admission.
• Upon admission and readmission, conduct a complete head-to-toe body assessment, describing any skin areas noted. Also, note body temperature, any soft tissue, any healed areas, dry or scaly skin areas, any painful areas, etc.
• Make the physician and family aware of any identified areas on the body that were not previously identified. Be sure to document that notification has been made.
• Initiate treatment of any identified areas per facility protocol or physician orders and notify appropriate staff (e.g., interdisciplinary team, dietary consultant, DON, etc.).
• Upon admission, complete a risk assessment using the Braden Scale or Norton Scale. Repeat this risk assessment when the resident is readmitted or when there has been a significant change in condition and again with each MDS assessment.
• Include interventions on the care plan to address any areas identified in the risk assessment that place the resident at a higher risk level for pressure ulcer development, such as impaired mobility, nutritional concerns, incontinence, etc. Also, be sure preventative interventions, such as pressure relief, incontinence care, etc., are included.
• Conduct pain assessment and pre-medicate the resident prior to treatment if pain occurs with treatment.
• Place the resident on a weekly ulcer assessment schedule, which works best if done by the same trained nurse. Report directly to the DON and administrator per facility policy. The purpose of this report is to allow the DON to have an overview of all areas in the facility and how they are progressing. The report should contain the following minimum information but could include more.
1. Anatomical location of the wound on the body
2. Whether the wound was inherited on admission or acquired while the resident was in the facility
3. Stage of the ulcer (you may want to include MDS staging as well as staging according to National Pressure Ulcer Advisory Panel standards)
4. Description of the wound, specifically, wound size (length, width, and depth) and any undermining/tunneling present—periwound tissue involvement (color, temperature, bogginess, and fluctuation) may also be included here as well, including wound bed tissue description and drainage or exudates present
5. Necrotic tissue and presence of any odor or other signs of infection
6. Healing progress compared to previous assessment (no change, improved, or deteriorated).
• Place resident on repositioning log to be monitored by licensed nurses on duty to ensure the patient’s position is being changed in a timely manner (see Table 1).
• The ulcer should be reassessed weekly with a thorough description placed in the medical record, including the same information as noted above (see Table 2). Some facilities utilize a pressure ulcer flow sheet to record this information. In any event, staff should know where to access this information. This should be done on the same day the body audit (head-to-toe assessment) is scheduled, so the nursing staff can refer to the status of the current ulcers from the information provided by the nurse conducting the pressure ulcer assessment.
• New ulcers have treatment initiated when discovered and are placed on the care plan with appropriate interventions to promote healing and/or prevent deterioration of the ulcer.
       While this may appear as a lengthy or cumbersome system, monitoring and managing pressure ulcers can be accomplished by utilizing a few tools, such as:
1. Risk assessment tool
2. Weekly body audit (head-to-toe assessment of skin) schedule—this works best if audits are rotated between shifts
3. Weekly ulcer report for the DON and administrator (as mentioned above)
4. Quality assurance monitoring tool that assures all systems are in place and assessments, documentation, notifications, etc. have been done—this may be done initially on all ulcers and then on all new ulcers, as well as random quarterly audits for quality assurance purposes
5. Repositioning logs—these should be used by supervisory staff to ensure residents’ positions are changed
6. Other quality assurance tools for checking treatment procedures, infections, documentation, and care planning interventions, etc. on a random basis.
       There are many resources available for information on development of systems, protocols, assessment tools, etc. including but not limited to the National Pressure Ulcer Advisory Panel (http://www.npuap.org) and the Medicare Quality Improvement Community (http://www.Medqic.org).
       In addition to systems, policies and procedures should be implemented to explain how and when each of the required components of the system are to be completed. Ongoing education should be mandatory for all staff regarding prevention and healing of pressure ulcers and should be included as part of nursing staff orientation.
       In most cases, where facilities utilize a system for monitoring and managing ulcers, lawsuits decrease in frequency and are more defensible, outcomes are better, and fewer deficiencies are cited regarding pressure ulcers—not to mention the dollar savings for the facility and improved dignity and quality of life for the resident.
       New Day Professional Services recently sponsored a Director of Nursing Boot Camp that focused on systems for success for monitoring and managing. A similar boot camp will be held in the Fall of 2004. Please visit http://www.newdayprofessionals.com for dates and locations.