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AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention

Facilitator Training—Handouts: Introduction to Pressure Ulcer Prevention Reports

Contents

Sample Nutrition Report: High Risk
Nutrition Report: Exercise To Spot Potential Inaccuracies
Sample Weight Summary Report
Sample Trigger Summary Report—Resident Level
Sample Trigger Summary Report—Unit Level
Trigger Summary Report: Resident Level: Exercise
Sample Risk Change Report: Resident Changes and Declines From Prior Week
Sample Intervention History for Nutrition Risk Report
Sample On-Time Resident Clinical, Functional, and Intervention Profile Report
Sample Completeness Report: Facility Level
Sample Completeness Report By Shift
   Day Shift
   Evening Shift
   Night Shift
 

Sample Nutrition Report: High Risk

High risk means the resident had decreased meal intake and weight loss during the report week.
 

Sample Nutrition Report
Unit A
Resident Room Number De- creased Intake: First Date Avg Meal Intake % 3/1/14 Avg. Meal Intake % 3/8/14 Avg Meal Intake % 3/15/14 Avg Meal Intake % 3/22/14 Diet TF Avg. Supple- ment Intake % Weight Change in lb Most Recent Ulcer Assess Date # Pr Ulcers
A 001 03/22/2014 50 41 36 29 Pureed
2/28/14		 X   -1.5 3/20/14 2
B 002 03/16/2014 64 52 47 45 Mech
1/22/14		   50% -3.3 3/20/14 1
C 003 03/19/2014 74 62 58 42 Reg
3/22/14		     -1.5    
D 004 03/17/2014 86 89 71 59 Reg
12/3/13		     -2.5    


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Nutrition Report: Exercise To Spot Potential Inaccuracies

Resident Room Number Decreased Intake: First Date Avg Meal Intake % 3/1/14 Avg. Meal Intake % 3/8/14 Avg Meal Intake % 3/15/14 Avg Meal Intake % 3/22/14 Diet TF Avg. Supple- ment Intake % Weight Change in lb Most Recent Ulcer Assess Date # Pr Ulcers
A 001 03/17/14 60 71 76 69 Pureed 8/10/13 X   ‐0.2    
B 002 03/18/14 94 92 97 85 Reg 9/10/12 ‐   ‐60.6    
C 003 03/17/14 49 52 37 32 Pureed 7/10/13 ‐ 50% ‐1.6    
D 004 03/19/14 33 75 31 92 Reg 6/30/13 ‐   ‐0.2    
E 005 03/20/14 10 11 0 0 Pureed ‐ 25% ‐212.2    
F 006 03/19/14 0 0 0 0 NPO 9/1/13 X   ‐2.2    
G 007 03/18/14 96 88 85 92 Reg 7/1/13 ‐   ‐10.5    
H 008 03/19/14 0 0 0 0 NPO 9/15/13 X   ‐0.8    
I 009 03/17/14 85 92 38 85 Mech 8/15/13 ‐   +1.2    
J 010 03/20/14 26 30 40 25 Pureed 5/14/13 ‐ 75% ‐1.8    
K 011 03/19/14 0 0 0 0 NPO 9/20/13     ‐1.0    
L 012 03/17/14 98 95 92 88 Reg 6/15/13 ‐   ‐6.1    


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Sample Weight Summary Report

Resi- dent Name Resi- dent ID > Weight 180 Days Prior Weight 90 Days Prior Weight 30 Days Prior Weight for Week 5/3/14 Week4 Weight for Week 5/10/14 Week3 Weight for Week 5/17/14 Week2 Weight for Week 5/24/14 Week1 Weight Change lb ≥2% Wt Loss (From Pre- vious Week) ≥5 lb Wt Loss in Prior 30 Days ≥5% Wt Loss in Prior 30 Days ≥5% Wt Loss in Prior 30 Days (Any) ≥7.5% Wt Loss in Prior 90 Days ≥10% Wt Loss in Prior 180 Days
A #####1 285.3 275.0 254.5 252.4 256.1 251.7 253.8 2.1, 5/24/14         7.7% 11.0%
B #####2 172.1 175.3 180.0 180.0 170.0 181.0 171.0 -10.0, 5/24/14 5.5% 9.0 5.6% 5.6%, 5/11/14; 5.0%, 5/24/14; 5.5%, 5/24/14    


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Sample Trigger Summary Report—Resident Level

Name Room Wt Loss ≥5% in Prior 30 Days (Any) Wt Loss ≥7.5% in Prior 90 Days (Point-to-Point) Wt Loss ≥10% in Prior 180 Days (Point-to-Point) 2 Meals ≤50% in 1 Day Weekly Meal Intake Average <50% Daily Urinary Incont >3 Days Bowel Incont Foley Catheter Current Pressure Ulcer # of Triggers Last Week # of Triggers This Week
Res1 330       X X X X     3 4
Res2 311 X     X -   X X   2 4
Res3 321 X X   X X   X     5 5
Res4 309     X   X X X     0 4
Res5 312     X - X X X     2 4
Res6 320   X   X - - X     0 3
Res7 342 X     X X         3 3
Res8 337       X   X X     2 3
Res9 301       X X X       1 3
Res10 316       X   X -   X 2 3
Total   3 2 2 8 6 6 7 1 1    


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Sample Trigger Summary Report—Unit Level

Pressure Ulcer Triggers Week 4
5/10/14		 Week 3
5/17/14		 Week 2
5/24/14		 Week 1
5/31/14
Wt Loss ≥ 5% in Prior 30 Days (Any) 1 (3%)(c) 2 (6%)(a) 1 (3%)(b) 1 (3%)(c)
Wt Loss ≥7.5% in Prior 90 Days (Point-to-Point) 1 (3%)(c) 1 (3%)(c) 1 (3%)(c) 1 (3%)(c)
Wt Loss ≥10% in Prior 180 Days (Point-to-Point) 1 (3%)(c) 2 (6%)(a) 1 (3%)(b) 2 (3%)(a)
2 Meals ≤50% in 1 Day 5 (14%)(c) 4 (11%)(b) 4 (11%)(c) 7 (20%)(a)
Weekly Meal Intake Average <50% 3 (9%)(c) 3 (9%)(c) 2 (6%)(b) 3 (9%)(a)
Daily Urine Incontinence 2 (6%)(c) 3 (9%)(a) 3 (9%)(c) 5 (14%)(a)
>3 Days Bowel Incontinence 5 (14%)(c) 4 (11%)(b) 3 (9%)(b) 7 (20%)(a)
Foley Catheter 8 (23%)(c) 7 (20%)(b) 5 (14%)(b) 8 (23%)(a)
Current Pressure Ulcer 0 (0%)(c) 0 (0%)(c) 0 (0%)(c) 0 (0%)(c)


Note: The report has been coded with (a) representing an increase, (b), a decrease, and (c), no change in weekly pressure ulcer trigger prevalence. 

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Trigger Summary Report: Resident Level: Exercise

Name Room Wt Loss ≥5% in Prior 30 Days (Any) Wt Loss ≥7.5% in Prior 90 Days (Point-to-Point) Wt Loss ≥10% in Prior 180 Days (Point-to-Point) 2 Meals ≤50% in 1 Day Weekly Meal Intake Average <50% Daily Urinary Incont >3 Days Bowel Incont Foley Catheter Current Pressure Ulcer # of Triggers Last Week # of Triggers This Week
Res1 A X   X X X     X X 3 6
Res2 B X     X X X X     5 5
Res3 C     X X X X X     2 5
Res4 D       X X X X     3 4
Res5 E X X   - - X X     2 4
Res6 F     X   X X X     0 4
Res7 G     X   X X X     2 4
Total   3 1 4 4 6 6 6 1 1    


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Sample Risk Change Report: Resident Changes and Declines From Prior Week

Name Room Number Nutrition Risk Change Within 7 Days
Increase in Incontinence ADL Decline# ≥3 Behaviors Pressure Ulcer Health Status#
Decreased Meal Intake + Weight Loss Decreased Meal Intake Weight > Loss ≥5% in Prior 30 Days Urine Bowel# Bed Mobility Transfer Toilet- ing Change in Behavior Types From Prior Week Worsen- ing Ulcer New Ulcer Acute Change in Status
Resident 1 202     X           7*      
Resident 2 212   X   X     X X       X
Resident 3 217 X     X X       3      
Resident 4 229     X     X            
Resident 5 231 X   X               X  
Resident 6 242     X                  
Resident 7 243                 4 X    

Note:

If three or more behaviors for a resident were documented during the current week, then the number of behaviors will display.

An asterisk (*) will display next to the number of behaviors if the behaviors recorded during the current report week are different from behaviors recorded during the prior week.

# indicates column added in 2014.

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Sample Intervention History for Nutrition Risk Report

# High-Risk Residents Room Diet Diet Changes Supple- ments PT OT Speech Social Services Psych Gastro-enterology Hospice Seen by: MD / PA or NP Chemistry Micro-biology Hema- tology
1 Brown, M 201 Regular 1/3 /14 10/4/13   1/2 /14 1/2 /14         1/2 /14 11/27/13 7/3/13 7/3/13
2 White, D 209 Regular 10/20/13 9/2/13     10/18/13 11/2/13 12/27/13 11/13/13   11/13/13 11/13/13 11/13/13 11/13/13
3 Green, D 212 Pureed 12/23/13               12/30/13 1/2 /14 1/2 /14 12/18/13 12/18/13
4 Orange, L 221 NPO 1/5 /14   12/15/13             1/3 /14 1/3 /14 6/2/13 6/2/13
5 Pink, S 222 Diabetic 7/22/13 12/31/13                 7/25/13 2/18/13 2/18/13
6 Silver, C 237 Low NA 12/18/13       11/29/13           5/12/13 5/12/13 5/12/13
7 Reddish, R 238 Regular 9/6/13           12/4/13       9/6/13 12/4/13 12/4/13
8 Black, B 240 Pureed 10/3/13     1/2 /14             2/18/13 12/4/13 12/4/13

Note: The Intervention History for Nutrition Risk Report is a new report added to the module in 2014. Only the report for the high-risk residents is shown. Separate reports for high and medium nutritional risk residents can be produced.

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Sample On-Time Resident Clinical, Functional, and Intervention Profile Report

  Week Ending
4/6/14 4/13/14 4/20/14 4/27/14
Vital Signs Number of pressure ulcers 0 1 2 2
Temperature   99.2    
Pulse 82 88 90 100
Respirations 20 20 20 20
Blood pressure 102/58 110/60 102/58 120/88
O2 saturation 96 97 98 88
Weight Weight in pounds 149.2     144
Weight date 3/26/14     4/23/14
Nutrition / Vitamins & Supplements Diet Pureed Pureed Pureed Clear liquids
Tube feeding No No No No
Supplements No Ensure Ensure Ensure
Multivitamin No No No Yes
Vitamin C No Yes Yes Yes
Arginaid No No No No
Zinc No No No No
Protein No No Yes Yes
Weekly average meal intake—percent        
   Breakfast 88 78 62 75
   Lunch 79 74 25 25
   Dinner 65 55 45 35
Nutritional supplement—percent        
   Breakfast 25 50 25 25
   Lunch 25 25 25 25
   Dinner 0 25 0 0
Bowel Habits Continent Continent Incontinent Incontinent
Loose stool No No Yes Yes
Incontinence        
   # shifts / week 0 0 12 18
   Daily incontinence       X
3 days without BM   X   X
Bladder Habits Incontinent Incontinent Incontinent Incontinent
Catheter Condom No No Foley
Ostomy No No No No
Incontinence        
   # shifts / week 9 12 12 14
   Daily incontinence No No Yes Yes
Did not void # shifts / week 0 0 0 1
Restorative Bowel No No No No
Bladder No No Yes Yes
Eating No No No No
Mobility No No No No
Self-Performance / Support Provided2 Bed mobility EA/1 EA/1 EA/1 EA/2
Transfer EA/1 EA/1 EA/1 EA/2
Locomotion EA/1 EA/1 EA/1 EA/2
Dressing LA/set up EA/1 EA/1 EA/1
Eating LA/set up EA/1 EA/1 EA/1
Personal hygiene LA/set up EA/1 EA/1 EA/1
Toileting EA/1 EA/1 EA/1 EA/2
Labs1 Pre-Albumin (19.5-35.8 mg/dL) 33.0   21.6  
Albumin (3.4-5.4 g/dL) 3.4 3.6 5.8* 6.2*
Sodium (135-145 mEq/L) 128* 122* 114* 120*
Potassium (3.5-5.2 mEq/L) 4.0 4.3 4.4 4.3
Creatinine (0.7-1.3 mg/dL) 0.6* 0.7 1.0 1.8*
BUN (6.0-20.0 mg/dL) 6.0 6.2 6.0 6.1
Transferrin (20-50%) 20 25 35 35
Bed Surfaces Air fluidized surface X X X X
Dynamic / alternating pressure        
Low air loss        
Replacement mattress        
Chair Surfaces Fluid filled or gel cushions X X X X
Foam cushions        
Combination cushions        
Other Heel boots X X X X

 
1. Lab normal value ranges used by the facility in parentheses.* Indicates abnormal value.
2. These abbreviations are based on MDS 3.0 ADL coding: Self-Performance—EA= extensive assistance; LA = limited assistance; and Total = total dependent; the abbreviation after the slash represents ADL support provided—set up=set up help only, 1 or 2 = how many staff provide physical assistance.

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Sample Completeness Report: Facility Level

Documentation Section 5/29/13 6/5/13 6/12/13 6/19/13
Meal Intake 92.2 93.1 90.4 92.0
Bowels 67.6 74.9 66.2 58.3
Bladder 54.8 61.7 78.2 86.9
Behaviors 53.1 69.9 87.1 91.0


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Sample Completeness Report By Shift

 Day Shift

Documentation Section 5/29/13 6/5/13 6/12/13 6/19/13
Meal Intake Breakfast 88.2 97.2 99.1 99.4
Meal Intake Lunch 98.4 96.2 92.2 96.6
Bowels 87.6 84.9 96.2 98.3
Bladder 54.8 61.7 78.2 86.9
Behaviors 53.1 69.9 87.1 91.0


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 Evening Shift

Documentation Section 5/29/13 6/5/13 6/12/13 6/19/13
Meal Intake Dinner 90.0 92.0 80.0 80.0
Bowels 97.6 94.9 96.2 98.3
Bladder 54.8 61.7 78.2 86.9
Behaviors 53.1 69.9 87.1 91.0


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 Night Shift

Documentation Section 5/29/13 6/5/13 6/12/13 6/19/13
Bowels 67.6 64.9 66.2 58.3
Bladder 54.8 61.7 78.2 86.9
Behaviors 53.1 69.9 87.1 91.0


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Return to Pressure Ulcer Prevention

Page last reviewed April 2016
Page originally created March 2013

Internet Citation: AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention. Content last reviewed April 2016. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/handouts.html

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