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

Handouts: Overview of On-Time (continued)

Self-Assessment Worksheet

Facility:

Date Completed: _________________________   

Completed By:__________________________________________________

Section 1: Screening for Pressure Ulcer Risk

In this section, we would like to learn more about your facility's pressure ulcer risk activities.

  1. Does your facility have a pressure ulcer risk policy?

    Yes _X_ No ___ If no, skip to Question 3.

  2. If yes, does the policy include the following:
  Yes No
a. Clinical areas to be covered X ___
b. Timing or frequency of assessments X ___
c. Documentation requirements X ___
d. Communication to care team ___ X
  1. Does your facility provide training to nursing staff on how to accurately assess for pressure ulcer risk?

    Yes ___ No _X_

  2. Does the pressure ulcer risk assessment use a standardized assessment tool (for example, Braden score or Norton tool)?<

    Yes ___ No _X_ If yes, skip to Question 6.

  3. If not using a standardized tool, does the assessment tool that the facility uses cover the following:
  Yes No
a. Impaired mobility X ___
b. Incontinence X ___
c. Nutritional deficits ___ X
d. Diabetes diagnosis ___ X
e. Peripheral vascular disease diagnosis ___ X
f. Contractures ___ X
g. History of pressure ulcers X ___
h. Paralysis ___ X
  1. How frequently is the risk assessment tool completed?
    1. ___ Monthly
    2. _X_ Quarterly
    3. ___ Annually
    4. ___ Change of condition
    5. ___ Other (specify): ____________________________________________________
  2. When are residents screened for pressure ulcer risk? Check all that apply.
    1. _X_ Upon admission/readmission
    2. ___ With a change in condition
    3. _X_ With each MDS assessment
    4. ___ When weight loss has occurred
    5. ___ Change in meal intake
    6. ___ Change in fluid intake
    7. ___ Change in mobility
    8. ___ Change in continence
    9. ___ Change in communication
  3. Do your facility's pressure ulcer risk assessment activities include a comprehensive skin assessment/inspection*?

    Yes _X_ No ___

    A comprehensive skin assessment is defined as a full head to toe and front Sand back assessment of the skin, the body's largest organ, for any breakdown or reddened areas. This includes attention to all bony prominences, ears, scalp, in between toes, etc.

  4. Who completes the skin assessment/inspection on admission?
    1. ___ Admitting nurse
    2. _X_ Nursing assistant
    3. ___ Wound/skin care nurse
    4. ___ Nurse manager
    5. ___ Nursing supervisor
    6. ___ Director of nursing
    7. ___ Other (specify)
  5. Who completes routine skin assessments/inspections?
    1. ___ Unit nurse
    2. _X_ Nursing assistant
    3. ___ Wound care nurse
    4. ___ Other (specify): ____________________________________________________
  6. How often are skin assessments/inspections completed?
    1. ___ Daily
    2. _X_ Weekly
    3. ___ Monthly
    4. ___ Other (specify): ____________________________________________________
  7. Where are skin assessments/inspections documented?
    1. ___ Medical record
    2. ___ Nursing assistant documentation
    3. _X_ Skin assessment form
    4. ___ Other (specify): ____________________________________________________
  8. Do you screen all residents for pressure ulcer risk at the following times:
    1. Upon admission: Yes _X_ No ___
    2. Upon readmission/reentry: Yes _X_ No ___
    3. When there is a change in condition: Yes ___ No _X_
    4. With each MDS assessment: Yes No _X_
  9. If the resident is not currently deemed at risk, is there a plan to rescreen at regular intervals?

    Yes ___ No _X_

  10. Do you screen residents for pressure ulcer risk with the following diagnoses?
    1. Diabetes mellitus: Yes ___ No _X_
    2. Peripheral vascular disease: Yes ___ No _X_
    3. History of pressure ulcer: Yes _X_ No ___
    4. Paralysis: Yes ___ No _X_

Section 2: Pressure Ulcer Prevention Plan

For residents at risk, we would like to learn what is included in your pressure ulcer prevention care plan.

  1. Do you develop a care plan for residents at risk of developing a pressure ulcer?

    Yes ___ No _X_ If not, skip to Section 3.

  2. Does your plan include interventions for skin care?

    Yes ___ No ___

  3. Does your plan include daily skin assessments of pressure points?

    Yes ___ No ___

    3A. Does your daily assessment assess the following areas?

    1. Sacrum: Yes ___ No ___
    2. Ischium: Yes ___ No ___
    3. Trochanters: Yes ___ No ___
    4. Heels: Yes ___ No ___
    5. Elbows: Yes ___ No ___
    6. Back of the head: Yes ___ No ___
    7. Ears/nose: Yes ___ No ___
  4. Does your plan include interventions addressing nutrition and hydration?

    Yes ___ No ___

    4A. Does your plan include interventions to address:

    1. Feeding or swallowing difficulties: Yes ___ No ___
    2. Undernourishment (e.g., weight loss, decreased meal intake) Yes ___ No ___
  5. Does your plan include a nutritional screen for residents at risk of developing a pressure ulcer?

    Yes ___ No ___

    5A. Does the screen include any of the following:

    1. Estimation of nutritional requirements: Yes ___ No ___
    2. Comparison of nutrient intake with estimated requirements: Yes ___ No ___
    3. Recommendation for frequency of reassessment of nutritional status: Yes ___ No ___
    4. Weight pattern change summary: Yes ___ No ___
  6. Does your plan include an assessment for pain?

    Yes _X_ No ___

  7. Does your plan include an assessment for decreased mental status?

    Yes ___ No ___

  8. Does your plan include an assessment for incontinence?

    Yes ___ No ___

  9. Does your plan include an assessment for medical device-related pressure?

    Yes ___ No ___

    9A. Do recommendations for positioning include the following?

    1. ___ Dealing with medical devices (oxygen tubing, catheters)
    2. Guidance for avoiding friction and shear
    3. Support surfaces
    4. Frequency of repositioning
  10. Does your plan include an assessment for friction and shear?

    Yes ___ No ___

    10A. Does your plan include an assessment for muscle spasms?

    Yes ___ No ___

  11. Does your plan include an assessment for immobility

    Yes ___ No ___

  12. Does your plan include an assessment for contractures?

    Yes ___ No ___

Section 3: Communication Practices

  1. We are interested in how you communicate the pressure ulcer risk and prevention care plans to the interdisciplinary team. Please review the following list of meetings. For every meeting that occurs at your facility, indicate how often it occurs, who leads the meeting, and who attends.
Meeting Pressure Ulcer Prevention Discussed Yes/No Meeting Chair/Leader Name and Discipline Staff Invited and in Attendance (indicate A—Always, V- Varies as needed) Frequency of Meeting (Weekly, Biweekly, Monthly, Quarterly, Change in Condition, As Needed)
a. Care plan review        
b. Report or brief with CNAs        
c. Report or brief with department heads        
d. Medical staff        
e. QAPI* or performance improvement plan meeting        
f. Skin or wound meeting        
g. MD/APRN* rounds        
h. Report or brief with Dietary Department        
i. Report or brief with Social Services Department        
j. Report or brief with Therapy Department        
k. Report or brief with "Other"        

QAPI = Quality Assessment and Performance Improvement; APRN = advanced practice registered nurse.

  1. Training

    Indicate the date of the most recent training provided for the following:

Topic Participants Date
a. Conducting an accurate skin assessment Nurses  
b. Conducting an accurate skin assessment CNAs  
c. Effective positioning Nurses  
d. Effective positioning CNAs  
e. Skin care CNAs  
f. Documentation—meal and fluid intake CNAs  
g. Documentation—positioning CNAs  

Section 4: Investigations/Root Cause Analysis of Pressure Ulcer Development

  1. Do you investigate each new in-house pressure ulcer according to your facility's policies and guidelines?

    Yes _X_ No ___ Not Sure ___

  2. Do you investigate each new in-house pressure ulcer in a root cause framework?
     

    Yes ___ No ___ Not Sure _X_ If no or not sure, stop here.

  3. In the course of your root cause analysis, do you look at the most recent pressure ulcer risk screen?
     

    Yes ___ No ___

    If yes, how do you check the accuracy of that screen? ____________________________
    _____________________________________________________________________________
     

  4. In the course of your root cause analysis, do you check to see if the risk status of the resident has changed?

    Yes ___ No ___

    If yes, would your investigation include any of the following factors as affecting risk for a pressure ulcer? Check all that apply.

    1. ___ Change in condition
    2. ___ Weight loss
    3. ___ Change in meal intake
    4. ___ Change in fluid intake
    5. ___ Change in mobility
    6. ___ Change in continence
    7. ___ Change in ability to communicate pain
    8. ___ Other (specify): ____________________________________________________
    9. ___ Other (specify): ____________________________________________________
  5. Please review the following list of assessments to identify appropriate interventions to address pressure ulcer risk. Check the one(s) that you would investigate as part of your root cause analysis:
    1. ___ Nutrition assessment for a resident with decreased meal or fluid intake
    2. ___ Nutrition screen for a resident at risk of developing a pressure ulcer
    3. ___ Pain assessment
    4. ___ Cognitive assessment
    5. ___ Incontinence assessment
    6. ___ Medical device-related pressure assessment (e.g., oxygen tubing, catheters)
    7. ___ Assessment for friction and shear
    8. ___ Mobility assessment
    9. ___ Contracture assessment
    10. ___ Assessment for appropriate bed and chair support surfaces
    11. ___ Positioning assessment
    12. ___ Skin assessments per frequency designated by MD/NP
    13. ___ Other (specify): ____________________________________________________
    14. ___ Other (specify): ____________________________________________________
  6. Assessments may reveal that a particular action should be taken (e.g., a toileting routine to prevent incontinence, diet change to encourage increased intake, new cushion for wheelchair). How would you find out if an intervention had been identified as necessary, but not carried out?

    _____________________________________________________________________________
    _____________________________________________________________________________
     

  7. Are there any particular obstacles or challenges to investigating the root cause of pressure ulcers?
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________

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Return to Pressure Ulcer Prevention

Page last reviewed October 2014
Page originally created March 2013
Internet Citation: AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/overviewhandouts2.html