Pressure ulcer litigation and regulatory citations in care centers continues to be on the rise. Pressure ulcers are commonly thought of as an avoidable incident. Therefore, it is implied that if a resident develops a pressure ulcer it must be due to neglect and poor care. As many of us in the industry know, our residents are more debilitated and medically complex then ever before. Due to the complexity of the medical conditions, many residents develop pressure ulcers despite good care and aggressive interventions.
Preventing a pressure ulcer or demonstrating that the pressure ulcer was unavoidable begins with the admission process. Although a care center’s overall pressure ulcer program must be strong, this article will focus on the admission process. Identification of risk factors and skin breakdown upon admission is a priority. Many care centers admit residents with current skin breakdown that they were unaware existed prior to admission. If the skin breakdown is not identified upon admission, the care center will have no choice but to label it as an in-house acquired pressure ulcer.
When looking at the screening process for admissions, you should ensure that it actively asks three key questions prior to admission. First, has the resident’s skin actually been observed? Second, have any skin concerns or breakdown been identified? And third, if there are skin concerns, what interventions are being utilized to treat the area? It is recommended that your questionnaire ask all three questions and that the responses are documented. The discharging hospital or care center should have responsibility and accountability for the condition of the skin upon discharge. This can also help you prepare for the admission in the event that special equipment or dressings need to be obtained prior to admission.
Upon admission the skin should be thoroughly inspected. A skin observation and documentation may seem simple, however, being able to identify lower extremity vascular concerns verses pressure ulcers and accurately being able to describe the current condition of the ulcer is actually very complex. All nurses should be trained on identification and documentation of pressure ulcers; however admission nurses in particular need emphasis in this area.
Admissions nurses need to be able to identify the underlying etiology in order to ensure the proper interventions are started upon admission. These same individuals need to thoroughly describe the area. Training should include identification of type of ulcer; arterial, venous, peripheral neuropathy, diabetic and/or pressure. The training should also include how to accurately describe the area, including how to measure length, width, and depth. How to describe the wound base, peri-wound, drainage, odor, undermining, tunneling and any pain associated with the area. In addition, the training should emphasize the fact that the staging system is for pressure ulcers only. If the skin is intact, it is particularly important that nurses can differentiate a suspected deep tissue injury from a stage I. The suspected deep tissue injury indicates that the area already involves deeper tissue damage. Therefore the area may digress exposing its true damage, despite diligent care.
In conjunction with a skin observation, a comprehensive pressure ulcer risk assessment should be completed and a temporary care plan developed within the first 24 hours. If a validated risk assessment such as a Braden scale is used, it is important to ensure that other risk factors are taken into account. Diagnosis, steroid use, low albumin or pre-albumin levels are just some examples of risk factors that should be recognized that the Braden scale might not identify. All risk factors identified by the comprehensive risk assessment should then be brought forward to the temporary care plan. Interventions should then be developed to help remove, modify or stabilize the identified risk factors.
A temporary care plan ideally includes the following interventions for residents at risk for skin breakdown:
- Pressure reduction surface on the bed
- Pressure reduction wheelchair cushion and/or referral to therapy if appropriate
- Individualized turning and repositioning intervals
- Dietary referral and interventions
- Incontinence management and barrier ointment to buttocks/perineum per elimination care plan problem
- Daily skin inspection with cares by nursing assistants
- Weekly skin inspection on bath/shower day by licensed staff
- Identified approach on how the heels will be elevated off of the bed if appropriate (i.e., pillow prop, heel lift boots, etc.)
- Notify the Physician/NP and family/designee if a wound develops
-
If the resident is admitted with skin breakdown the temporary care plan should also include:
- Treatment as ordered
- Weekly wound assessment
- Monitor for S/S of infection
- Notify the Physician/NP and family/designee of the wound status on a timely basis as appropriate
Once the temporary care plan is developed, the interventions need to be communicated to the nursing assistants and appropriate staff.
Implementation and documentation within the first 24 hours of admission can help care centers prove unavoidability. Certainly, if it is not documented does not mean the wound didn’t exist or that the care wasn’t provided. However, thorough documentation can help establish that the care was provided and a description of what the condition of the skin was in when the resident was admitted.