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Assessing Nursing Home residents for risk of skin breakdown

The following is a sample policy that may be implemented in certain nursing homes regarding assessment of nursing home residents for risk skin breakdown.

It is the responsibility of the facility staff via the interdisciplinary team to recognize any resident who is at-risk for pressure ulcer development and initiate appropriate preventive measures. The prevention and treatment of pressure ulcers begins with an assessment of the resident's skin integrity and any existing predisposing factors.

The Nursing Department should complete a Braden Scale risk assessment tool upon admission and initiate prevention measures as indicated. A weekly assessment of all residents with pressures ulcers should be conducted through pressure ulcer rounds and findings will be documented on Weekly Skin Integrity Flow sheet. Revision of the CCP will be completed as indicated by the interdisciplinary team's discussion and recommendations.

The facility's interdisciplinary team will conduct ongoing monitoring of the facility's skin integrity program to ensure that appropriate preventive interventions are in place for "at risk" residents and residents with actual pressure ulcers will have a plan of care implemented to promote healing of ulcer as quickly as possible.

The goal is to provide a standardized approach to skin assessment prevention of pressure ulcers and interdisciplinary evaluation and management of pressure ulcers when necessary.

The licensed nurse is responsible for completing the initial skin assessment and Braden Risk upon admission. The Braden Risk Assessment is completed quarterly and upon significant change. Risk factors may also be identified through the MDS 2.0 assessment process.

The CNAs are responsible for verbally reporting and documenting on a daily basis, any changes noted In their assigned resident's skin integrity.

The Licensed Nurse is responsible to assess resident;s skin conditions at time of dressing change. If additional pressure ulcers are identified the Physician is notified and a treatment order is obtained.

The Charge Nurse or designee is responsible for assessing the wounds every week and recording findings on Weekly Skin Integrity Flow Sheet.

Based on the resident assessment and evaluation process, an individual CCP will be initiated by the Licensed Nurse. Additional interventions will be included by the interdisciplinary team.

The resident's pain level is assessed and is medicated prior to treatment. If indicated, Resident's "at risk" for pressure ulcers will have a preventative plan implemented.

Residents with an actual pressure ulcer will have a care plan implemented that documents an Interdisciplinary approach to the healing of the pressure ulcer following facility protocols as well as appropriate preventive measures. The Licenced Nurse will complete and forward the Pressure Ulcer Notification Form to the Medical Director, Rehab Nurses, Clinical Nurse Manager, Supervisor and the Dietary Department. The Clinical Nurse Manager will conduct an investigation re: any nosocomial pressure ulcer and complete the Nosocomial Pressure Ulcer Investigation Report, and submit it to the Rehab Nurse.

The resident will be placed on the 24 hour sheet for 72 hours (3 days) to ensure that all staff are aware of the resident's skin condition.

The Charge Nurse will update the CNA Accountability Record at the time the pressure ulcer is identified or changes have been made in the care plan. This updating should include information such as the established turning and positioning schedule, out of bed schedule- toileting schedule. adaptive/assistive devices- etc.

Turning and positioning is to be done per schedule specified utilizing the Universal Clock System. The Turning clock sheet should be placed on the closet door or on the back of the door in the Resident's room.

Residents with a newly identified pressure ulcer will be evaluated by the Rehab Nurse and the interdisciplinary team for appropriate interventions.

The progress of the resident's pressure ulcer will be monitored on a weekly basis by the primary care team through Pressure Ulcer Rounds to ensure appropriate management of pressure ulcer, The nurse will complete the Weekly Skin Integrity Flow Sheet. Each ulcer should be documented on the skin integrity flow sheet.

The progress of the pressure ulcer will be reviewed by appropriate members of the interdisciplinary team.

The resident will be placed on the 24 hour sheet for 72 hours (3 days) to ensure that all staff are aware of the resident's skin condition.

The progress of the pressure ulcer will be reviewed by appropriate members of the interdisciplinary team, by the Attending Physician or designee and a surgical consult implemented, if will be ordered on all residents with a pressure ulcer upon identification of a stage Il ulcer and then quarterly and PRN (see protocol).

Pressure ulcers that progress to a stage Ill or IV will have a significant change assessment (MDS 2.0) done or when there is an emergence of a pressure ulcer stage Il with other related significant clinical changes.

The Dietary Department is responsible for reviewing the medical record of any resident who develops a pressure ulcer and making recommendations to the attending physician regarding vitamin and mineral supplements as well as additional protein.

The charge nurse will notify family/legal representative of the development of a stage Il or greater pressure ulcer.

Pressure ulcer statistics. analysis, corrective actions and other pertinent data will be collected and reported monthly by the Rehab Nurse. The VP of Nursing will report monthly statistic to the Medical Director and the Quality Performance Improvement committee.

Quality Performance Improvement monitoring will be completed by the Rehab Nurse/Designee. An audit of 10% of all residents with pressure ulcers will be completed monthly (using the Pressure Ulcer Documentation Audit Tool),


Stage I

Non-blanchable erythema of intact skin. In individuals with darker skin. discoloration of the skin. warmth. edema, induration. or hardness mav also be indicators.

Stage Il Partial thickness skin loss involving epidermis, dermis or both. The small ulceration is superficial and presents clinically as an abrasion, blister or shallow crater.

Stage III

Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

Stage IV Full thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bones or supporting structures (e.g. tendon- joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure.

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