AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Facilitator Training—Handouts: Pressure Ulcer Prevention Implementation
Implementation of the Prevention Reports Into Day-to-Day Practice
Review of the Nursing Home's Pressure Ulcer Prevention Implementation
Scripted Exercise #1
- Completed Self-Assessment Worksheet for use with Scripted Exercise #1 (Greenleaf Hills Nursing Home)
- Scripted Exercise #1
Unscripted Exercise #2
- Bios for Role-Play Characters for use with Unscripted Exercise #2
- Completed Self-Assessment Worksheet for use with Unscripted Exercise #2 (Shady Manor Nursing Home)
- Suggested Prompts for Facilitators
Review of the Change Team's Process of Choosing On Time Reports, Incorporating Them Into Huddles and Meetings, and Piloting Those Meetings
Scripted Exercise #1
- Completed Menu of Implementation Strategies Worksheet for use with Scripted Exercise #1
- Completed Communication Practice Grid from Self-Assessment Worksheet for use with Scripted Exercise #1
- Meeting Descriptions document
- Scripted Exercise #1
Unscripted Exercise #2
- Completed Menu of Implementation Strategies Worksheet for use with Unscripted Exercise #2
- Completed Communication Practice Grid from Self-Assessment Worksheet for use with Unscripted Exercise #2
- Suggested Prompts for Facilitators
Review of the Nursing Home's Pressure Ulcer Prevention Implementation: Scripted Exercise #1
Completed Self-Assessment Worksheet
Facility Name: Greenleaf Hills Nursing Home
Date Completed: 7/30/14 Completed By: DON, ADON
Section 1: Screening for Pressure Ulcer Risk
In this section, we would like to learn more about your facility's pressure ulcer risk activities.
-
Does your facility have a pressure ulcer risk policy?
Yes _X_ No ___ If no, skip to Question 3.
- 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 |
-
Does your facility provide training to nursing staff on how to accurately assess for pressure ulcer risk?
Yes ___ No _X_
-
Does the pressure ulcer risk assessment use a standardized assessment tool (for example, Braden score or Norton tool)?
Yes _X_ No ___ If yes, skip to Question 6.
- If not using a standardized tool, does the assessment tool that the facility uses cover the following:
Yes | No | |
---|---|---|
a. Impaired mobility | ||
b. Incontinence | ||
c. Nutritional deficits | ||
d. Diabetes diagnosis | ||
e. Peripheral vascular disease diagnosis | ||
f. Contractures | ||
g. History of pressure ulcers | ||
h. Paralysis | X |
- How frequently is the risk assessment tool completed?
- ___ Monthly
- _X_ Quarterly
- ___ Annually
- ___ Change in condition
- ___ Other (specify): _________________________________________________________
- When are residents screened for pressure ulcer risk? Check all that apply.
- _X_ Upon admission/readmission
- _X_ With a change in condition
- _X_ With each MDS assessment
- ___ When weight loss has occurred
- ___ Change in meal intake
- ___ Change in fluid intake
- ___ Change in mobility
- ___ Change in continence
- ___ Change in communication
-
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 and 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.
- Who completes the skin assessment/inspection on admission?
- _X_ Admitting nurse
- _X_ Nursing assistant
- ___ Wound/skin care nurse
- ___ Nurse manager
- ___ Nursing supervisor
- ___ Director of nursing
- ___ Other (specify)
- Who completes routine skin assessments/inspections?
- ___ Unit nurse
- _X_Nursing assistant
- ___ Wound care nurse
- ___ Other (specify): _________________________________________________________
- How often are skin assessments/inspections completed?
- ___ Daily
- _X_ Weekly
- ___ Monthly
- ___ Other (specify): _________________________________________________________
- Where are skin assessments/inspections documented?
- ___ Medical record
- ___ Nursing assistant documentation
- _X_ Skin assessment form
- ___ Other (specify): _________________________________________________________
- Do you screen all residents for pressure ulcer risk at the following times:
- Upon admission: Yes _X_ No ___
- Upon readmission/reentry: Yes _X_ No ___
- When there is a change in condition: Yes _X_ No ___
- With each MDS assessment: Yes ___ No _X_
-
If the resident is not currently deemed at risk, is there a plan to rescreen at regular intervals?
Yes ___ No _X_
- Do you screen residents for pressure ulcer risk with the following diagnoses?
- Diabetes mellitus: Yes ___ No _X_
- Peripheral vascular disease: Yes ___ No _X_
- History of pressure ulcer: Yes _X_ No ___
- Paralysis: Yes _X_ No ___
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.
-
Do you develop a care plan for residents at risk of developing a pressure ulcer?
Yes _X_ No ___ If not, skip to Section 3.
-
Does your plan include interventions for skin care?
Yes _X_ No ___
-
Does your plan include daily skin assessments of pressure points?
Yes ___ No _X_
3A. Does your daily assessment assess the following areas?
- Sacrum: Yes ___ No ___
- Ischium: Yes ___ No ___
- Trochanters: Yes ___ No ___
- Heels: Yes ___ No ___
- Elbows: Yes ___ No ___
- Back of the head: Yes ___ No ___
- Ears/nose: Yes ___ No ___
-
Does your plan include interventions addressing nutrition and hydration?
Yes _X_ No ___
4A. Does your plan include interventions to address:
- Feeding or swallowing difficulties: Yes ___ No _X_
- Undernourishment (e.g., weight loss, decreased meal intake): Yes _X_ No ___
-
Does your plan include a nutritional screen for residents at risk of developing a pressure ulcer?
Yes ___ No _X_
5A.Does the screen include any of the following:
- Estimation of nutritional requirements: Yes ___ No ___
- Comparison of nutrient intake with estimated requirements: Yes ___ No ___
- Recommendation for frequency of reassessment of nutritional status: Yes ___ No ___
- Weight pattern change summary: Yes ___ No ___
-
Does your plan include an assessment for pain?
Yes ___ No _X_
-
Does your plan include an assessment for decreased mental status?
Yes ___ No _X_
-
Does your plan include an assessment for incontinence?
Yes _X_ No ___
-
Does your plan include an assessment for medical device-related pressure?
Yes ___ No _X_
9A. Do recommendations for positioning include the following?
- ___ Dealing with medical devices (oxygen tubing, catheters)
- ___ Guidance for avoiding friction and shear
- ___ Support surfaces
- ___ Frequency of repositioning
-
Does your plan include an assessment for friction and shear?
Yes _X_ No ___
10A. Does your plan include an assessment for muscle spasms?
Yes ___ No _X_
-
Does your plan include an assessment for immobility?
Yes _X_ No ___
-
Does your plan include an assessment for contractures?
Yes _X_ No ___
Section 3: Communication Practices
- 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 | Yes | Nurse Manager | Nursing – A Social Services – A Activities – A Rehab – V Dietitian – A |
Weekly |
b. Report or brief with CNAs | No | Nurse Manager | Nursing Assistants – A | Every shift |
c. Report or brief with department heads | No | DON | Department heads (Nursing, Activities, Social Service, Rehab, Dietary, Maintenance and Housekeeping) – A | Daily |
d. Medical staff | No | N/A | N/A | N/A |
e. QAPI* or performance improvement plan meeting | Yes, if pressure ulcers are a problem | DON | Department heads and medical director – A | Quarterly |
f. Skin or wound meeting | No, unless the resident has a pressure ulcer | ADON | Nursing – A Rehab – A Nursing assistants – V |
Weekly |
g. MD/APRN* rounds | No | N/A | N/A | N/A |
h. Report or brief with Dietary Department | No | N/A | N/A | N/A |
i. Report or brief with Social Services Department | No | N/A | N/A | N/A |
j. Report or brief with Therapy Department | No | N/A | N/A | N/A |
k. Report or brief with "Other" |
* QAPI = Quality Assessment and Performance Improvement; APRN = advanced practice registered nurse.
-
Training
Indicate the date of the most recent training provided for the following:
Topic | Participants | Date |
---|---|---|
a. Conducting an accurate skin assessment | Nurses | On hire |
b. Conducting an accurate skin assessment | CNAs | 3-14-14 |
c. Effective positioning | Nurses | On hire |
d. Effective positioning | CNAs | 6-6-14 |
e. Skin care | CNAs | 2-12-14 |
f. Documentation—meal and fluid intake | CNAs | 4-16-14 |
g. Documentation—positioning | CNAs | 5-14-14 |
Section 4: Investigations/Root Cause Analysis of Pressure Ulcer Development
-
Do you investigate each new in-house pressure ulcer according to your facility's policies and guidelines?
Yes _X_ No ___ Not Sure ___
-
Do you investigate each new in-house pressure ulcer in a root cause framework?
Yes ___ No ___ Not Sure _X_ If no, stop here.
-
In the course of your 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?
____________________________________________________________________________ -
In the course of your 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.
- ___ Change in condition
- ___ Weight loss
- ___ Change in meal intake
- ___ Change in fluid intake
- ___ Change in mobility
- ___ Change in continence
- ___ Change in ability to communicate pain
- ___ Other (specify): ________________________________________________________
- ___ Other (specify): ________________________________________________________
- 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:
- ___ Nutrition assessment for a resident with decreased meal or fluid intake
- ___ Nutrition screen for a resident at risk of developing a pressure ulcer
- ___ Pain assessment
- ___ Cognitive assessment
- ___ Incontinence assessment
- ___ Medical device-related pressure assessment (e.g., oxygen tubing, catheters)
- ___ Assessment for friction and shear
- ___ Mobility assessment
- ___ Contracture assessment
- ___ Assessment for appropriate bed and chair support surfaces
- ___ Positioning assessment
- ___ Skin assessments per frequency designated by MD/NP
- ___ Other (specify): ________________________________________________________
- ___ Other (specify): ________________________________________________________
-
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?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
-
Are there any particular obstacles or challenges to investigating the causes of pressure ulcers?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Review of the Nursing Home's Pressure Ulcer Prevention Implementation: Scripted Exercise #1
Change Team Meeting
Setting: The DON and ADON completed the facility's Pressure Ulcer Prevention Self-Assessment. The Facilitator and Champion have reviewed the completed self-assessment and decided in advance that the Facilitator will lead the team meeting. The team meeting has been scheduled and is about to start. In attendance are the Facilitator, the Program Champion, the DON, the ADON, the Nurse Manager, the Nursing Supervisor, the Dietitian, the Rehab Director, the QI coordinator/MDS nurse, and the Nursing Assistant.
Facilitator: Good morning, team, and welcome back to the On-Time training. We are meeting today because we're going to review the completed self-assessment and begin thinking about how you might use the On-Time reports.
Let's review where we are in the training process. Last week we covered the introductory sections, which gave us an overview of the On-Time reports and implementation process. We also started talking about the reports that you've decided to implement, Pressure Ulcer Prevention, and we've gone over each of the electronic reports that are part of it. Today we've going to review the self-assessment that nursing completed. Does everyone have a copy of the completed self-assessment?
Program Champion: I want everyone to understand that the information on the self-assessment and what we'll talk about today will not be shared with anyone outside of our facility. We're here to review the self-assessment and think, as a team, about ways that we can improve prevention. Remember, after a pressure ulcer occurs, it's all well and good to think about what happened, but for the resident, it's too late. We want our efforts to be directed at identifying those residents at risk and doing something about it before the pressure ulcer occurs.
Nurse Manager: Isn't every resident at risk?
Program Champion: Yes, that's true, but some are more at risk than others and for different reasons. We want to prioritize which residents we focus prevention activities on, persons at risk for specific risk factors, persons at high risk for pressure ulcers and whose risk factors have recently changed. We want to intervene with them as early as possible.
Facilitator: Are there any questions? O.K., then let's get started. Completion of the self-assessment was a group effort. Joanne [ADON] and Mary [DON] worked on it. They completed it last week and Tom [Program Champion] and I reviewed it before our meeting today.
DON: Yes, I reviewed it also and I think it shows some interesting information about our facility.
Facilitator: Thanks, Mary [DON], and I agree. I think we have a lot to talk about. Thank you for sharing the self-assessment with me. The purpose is to identify what the facility is currently doing to help identify ways the On-Time pressure ulcer prevention can help strengthen prevention activities. The self-assessment is divided into four sections: Screening for Risk, Prevention Programs, Communication Practices, and Investigations Into Adverse Events. Let's start with Screening for Risk.
Facilitator: Your self-assessment shows that you use the Braden scale. Are there any particular barriers or challenges that you've faced when using the Braden?
Nurse Manager: Each resident's Braden score is updated every quarter and I think we do a pretty good job of staying on schedule. We do it when we're doing the MDS assessment. But, if we're talking about prioritizing residents at high or changing risk, it seems that we should have more up-to-date information.
Facilitator: That's a good point, Nancy [Nurse Manager]. What do the rest of you think? How do you monitor the resident's risk as it changes from week to week?
Nursing Assistant: I fill out the ADL sheets on my residents every shift- that goes into the computer. If there's a major change, I report it to the charge nurse.
Facilitator: O.K. Nurse Manager, what do you do with the information you get from the nursing assistants?
Nurse Manager: We put it in the nurses' notes in the medical record and on the 24-hour report.
Facilitator: O.K. And how is that shared with the rest of the care team? Folks from rehab, how do you hear about these changes?
Rehab: We don't hear about changes day to day from the 24-hour report. We usually hear about changes at the care plan meetings or sometimes we get a call or email from the Nurse Manager about a particular resident.
Nursing Supervisor: Major changes or concerns, we report at standup meeting when all department heads are there.
Facilitator: I see. Major changes or concerns are reported at standup meeting with department heads. What is the process for this team to make decisions and determine interventions? Who carries out the interventions and follows up? How do you think this process is working? Are those residents at risk or with changing risk factors being identified? Do you think subtle changes are being picked up? Are interventions being put in place for them? And, is everyone informed of the interventions?
Dietitian: Major changes are communicated pretty well, but I worry about the subtle changes. If I want to see meal intakes for the residents over several weeks, I have to go to individual intake sheets in each resident's record. That's pretty hard to do when you're covering 80 residents.
Nurse Manager: I agree. If I'm not mistaken, the Nutrition Reports can track that kind of information over 4 weeks.
Dietitian: That would really be helpful.
ADON: I think we do a pretty good job of communicating about our residents. We have lots of meetings—morning report, standup meeting, huddles, fall meetings, pressure ulcer meetings, QI meetings. I don't think it's a case of not having enough meetings. I think the problem is tracking the information. It's a lot of work to keep track of what's been done for each resident and to have an updated picture of the resident's risk profile and make sure that everyone on the team has been updated. We don't do that very well.
Facilitator: We're going to talk about those meetings, but first, let's talk about your prevention practices. Do you feel that what you're doing for pressure ulcer prevention could be improved?
Dietitian: I analyze calorie and fluid intake and develop nutritional interventions for residents with weight loss, but that's after the weight loss has occurred. I'd rather be alerted to signs of pending weight loss before it becomes a problem—like if the resident is eating a lot less—and before it leads to a pressure ulcer. I know that there are nutrition risk reports in On-Time, but I need to connect with the nursing assistants to verify the information and would like to have their input on interventions.
ADON: Are you talking about adding another meeting?
Facilitator: Let's talk about those meetings. I see from your self-assessment, you do have a lot of meetings. I noticed that nursing assistants were not listed as attending any of the meetings. Is that true?
Nursing Assistant: We used to attend care plan meetings, but not lately.
Nurse Manager: It's really hard to send them off the floor for a meeting. That means that someone has to cover their assignment while they're gone. That leaves the floor really short-handed—and the residents at risk.
Facilitator: I understand, but could there be another way to include input from the nursing assistants without having them attend the whole meeting? Or, what if they attended for just a few minutes to provide an update on the resident? Could the nursing assistant attend the meeting for 10 minutes?
Nurse Manager: Maybe she could give a report to the MDS nurse, but she wouldn't be there to respond to any questions. I think it's best if the nursing assistant attends. Since the meetings are in the afternoon, maybe someone from the next shift could come in a little early to help out.
Facilitator: Hold that thought. We're going to strategize about how to add discussions of risk factors into facility meetings—and how to make these productive discussions with input from all members of the care team—in our next session. Let's finish up on the self-assessment.
Another thing I noticed about your meetings is that pressure ulcer prevention is discussed at only one meeting, the pressure ulcer meeting. Is that true?
Rehab: Yes, I'm at the pressure ulcer meeting and we do discuss positioning, and support surfaces, but that's true usually for people who already have a pressure ulcer.
QI Improvement Coordinator/MDS Nurse: We also talk about pressure ulcer prevention at care plan meetings, if the resident has had a pressure ulcer in the past.
Program Champion (excitedly): Exactly! We discuss prevention of new pressure ulcers after someone has had one. The whole point of this is to talk about and do something about it before the pressure ulcer happens.
Facilitator: That's right, Tom [Program Champion], but changing the way we think about prevention and acting on risk factors rather than reacting to an adverse event that has already happened is a process. And, as everybody knows, changing the way you do things takes practice. The first step is to recognize that we have some tools, the On-Time reports that can help us make these changes. Lastly, let's review the fourth section of the self-assessment on investigations or root cause analysis of pressure ulcer development.
DON: We haven't started doing that yet. Whenever a new pressure ulcer is noted, we review what happened, but we don't call it root cause analysis.
Facilitator: What exactly do you do as part of your review?
DON: We look at the contributing factors, like maybe the person was a diabetic, or was paralyzed and couldn't move well by themselves. We put measures in place to make sure that another pressure ulcer doesn't develop.
Facilitator: O.K. The On-Time reports can help you look at the risk factors that the resident had before they developed the pressure ulcer. You can check to see if those risk factors had been noted and addressed and then apply what you learn to other residents or to do teaching or training with your staff. For example, if you had the On-Time reports, you could look back prior to the date that the resident's ulcer was first noted and see what his or her risk factors were. Suppose the On-Time reports showed that this resident had gradually been decreasing his meal intake and had also been gradually moving less on his own, this would alert you to look for other residents with similar declines and address these risk factors in their care plans. You might also want to do further training with nursing assistants to reinforce with them how important it is to pass on this type of information.
DON: So, the On-Time report can help us in this area as well. That's great.
Facilitator: To wrap up, let's quickly recap what we've heard today:
- Input from nursing assistants at meetings is valuable but their attendance at meetings is difficult to manage given their workload.
- There are many meetings happening at this nursing home, but their focus seems to be on reacting to adverse events that have already occurred, rather than prevention.
- There are concerns about adding new meetings.
- There are concerns that the information on risk and changing risk may not be readily available to members of the care team.
Does that accurately sum it up?
Program Champion: Yes.
Facilitator: But, there's hope. I think the On-Time reports could be very helpful to you. They can provide timely information on risk and changing risk to those making care decisions. I will work with you to identify the reports you want to adopt, and how to integrate the use of the reports into existing meetings. If you decide a new meeting will be needed to communicate the information, I'll help you through that process as well. That will be the focus of our next session.
Thanks for a great discussion, team.
Review of the Nursing Home's Pressure Ulcer Prevention Implementation: Unscripted Exercise #2
Bios for Role-Play Characters
- Facilitator: Sam is an experienced quality improvement consultant but new to the facilitator role. He knows nursing home operations, has provided educational programs in the nursing home setting, and has great respect for the work that the nursing assistants do.
- Sam's role is to keep people on track to accomplish the review of the self-assessment, that is, he helps the group move through the review of each section.
- He interjects whenever he can to promote the value of On-Time and the findings from the self-assessment (see Important Points list).
- Program Champion/Administrator: Carol is a brand new administrator; new to the role and new to the facility, but very enthusiastic about On-Time. She really wants to see On-Time succeed at her facility.
- She is very enthusiastic and supportive of On-Time. She is often quoted as saying, "See how great this will be in our facility."
- Her role is to assist the facilitator in reminding team members of the value of On-Time (see Important Points list).
- DON: Edna has been the DON of this facility for 25 years and a nurse for 40 years. She has seen many programs come and go (including administrators). She runs a "tight ship," knowing everything that goes on in the building. She convinced administration to purchase their current EMR system and wants to see it used to its fullest potential. She is a huge proponent of On-Time.
- Edna's role is as a decisionmaker. She knows how things are done at the facility and has the authority to make decisions; she backs up the Program Champion when others start to voice doubts about On-Time.
- Edna is used to getting what she wants. She has been the constant in this facility and people look to her to make decisions.
- ADON: Maureen is quiet and soft-spoken and a little intimidated by the DON. She has been at the facility for about 5 years and really loves the residents. She is also responsible for providing staff education and new employee orientation.
- Maureen knows the meetings that occur at the facility; she has good rapport with the Nurse Manager and nursing assistants. She can be counted on to act as a negotiator.
- Maureen likes when everyone gets along and tries to avoid conflict or arguments.
- Maureen is neutral about On-Time.
- Nursing Supervisor: Janet is going to school to be a geriatric nurse practitioner and working part-time. She's very interested in physical assessment, quality metrics, and quality improvement. She often tries to suggest to the QI nurse and Nurse Managers what they should be doing. It is not always well received.
- Janet's role is to push for more quality improvement. She believes the facility hasn't done enough to promote quality improvement.
- Dietitian: Linda works 2 days a week at the facility. She does her work and tries to avoid the DON. She loves to look at data and is very interested in seeing On-Time implemented.
- Laura's role is to promote the use of data in the nursing home.
- Rehab Director: Frank is an experienced physical therapist. He works part-time at the nursing home. He'd like to build up the rehab practice at the nursing home so that his job could be full-time, but gets resistance from the DON when he suggests any kind of changes to increase the caseload. He sees On-Time as possibly helping him find residents who could benefit from rehab and increase his caseload.
- Frank's role is to promote the use of the On-Time reports to identify residents who could benefit from additional therapy.
- Nursing Assistant: Jenny works full-time at this nursing home and part-time at another home. She has a family to care for in addition to her two jobs, which she loves because of the residents. But she's tired much of the time. She feels that the clinical staff appreciate her knowledge of the residents, but not how much she does to help them. She likes the idea that her documentation in the EMR is valuable and likes the possibility of attending some clinical meetings although she is worried she will be working even harder and may not be able to finish her work (and leave) on time.
- Jenny's role is to give good care, but get her work done so she can leave on time.
- Nurse Manager: Beth runs one of the long-term care units. She has a good relationship with her nursing assistants and with the families of her residents. She loves the residents and is often seen sitting down to chat with them in the activities room. She doesn't like paperwork (or the new EMR) and thinks that most of it is just unnecessary and gets in the way of "real" nursing.
- Beth's role is to raise objections to adding more meetings that she thinks just take her away from caring for the residents.
- Beth really doesn't like having to learn the EMR system either. She didn't go to school for IT, she went for nursing.
- QI Coordinator/MDS Nurse: Jackie covers quality improvement and acts as the MDS nurse. She is drowning in work and often is late getting the MDSs completed. She worries that the State surveyors will come in and discover she is behind on the assessments.
- Jackie's role is to get as much information about the residents as quickly as possible. She doesn't necessarily want to sit in more meetings; she just wants the information to use for her MDS assessments.
Review of the Nursing Home's Pressure Ulcer Prevention Implementation: Unscripted Exercise #2
Completed Self-Assessment Worksheet
Facility: Shady Manor Nursing Home
Date Completed: 8/14/14 Completed By: ADON
Section 1: Screening for Pressure Ulcer Risk
In this section, we would like to learn more about your facility's pressure ulcer risk activities.
-
Does your facility have a pressure ulcer risk policy?
Yes _X_ No ___ If no, skip to Question 3.
- 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 |
-
Does your facility provide training to nursing staff on how to accurately assess for pressure ulcer risk?
Yes ___ No _X_
-
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.
- 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 | X |
- How frequently is the risk assessment tool completed?
- ___ Monthly
- _X_ Quarterly
- ___ Annually
- ___ Change in condition
- ___ Other (specify): _________________________________________________________
- When are residents screened for pressure ulcer risk? Check all that apply.
- _X_ Upon admission/readmission
- ___ With a change in condition
- _X_ With each MDS assessment
- ___ When weight loss has occurred
- ___ Change in meal intake
- ___ Change in fluid intake
- ___ Change in mobility
- ___ Change in continence
- ___ Change in communication
-
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 and 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.
- Who completes the skin assessment/inspection on admission?
- ___ Admitting nurse
- _X_ Nursing assistant
- ___ Wound/skin care nurse
- ___ Nurse manager
- ___ Nursing supervisor
- ___ Director of nursing
- ___ Other (specify) _______________________________________________
- Who completes routine skin assessments/inspections?
- ___ Unit nurse
- _X_Nursing assistant
- ___ Wound care nurse
- ___ Other (specify): _________________________________________________________
- How often are skin assessments/inspections completed?
- ___ Daily
- _X_ Weekly
- ___ Monthly
- ___ Other (specify): _________________________________________________________
- Where are skin assessments/inspections documented?
- ___ Medical record
- ___ Nursing assistant documentation
- _X_ Skin assessment form
- ___ Other (specify): _________________________________________________________
- Do you screen all residents for pressure ulcer risk at the following times:
- Upon admission: Yes _X_ No ___
- Upon readmission/reentry: Yes _X_ No ___
- When there is a change in condition: Yes ___ No _X_
- With each MDS assessment: Yes ___ No _X_
-
If the resident is not currently deemed at risk, is there a plan to rescreen at regular intervals?
Yes ___ No _X_
- Do you screen residents for pressure ulcer risk with the following diagnoses?
- Diabetes mellitus: Yes ___ No _X_
- Peripheral vascular disease: Yes ___ No _X_
- History of pressure ulcer: Yes _X_ No ___
- 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.
-
Do you develop a care plan for residents at risk of developing a pressure ulcer?
Yes ___ No _X_ If not, skip to Section 3.
-
Does your plan include interventions for skin care?
Yes ___ No ___
-
Does your plan include daily skin assessments of pressure points?
Yes ___ No ___
3A. Does your daily assessment assess the following areas?
- Sacrum: Yes ___ No ___
- Ischium: Yes ___ No ___
- Trochanters: Yes ___ No ___
- Heels: Yes ___ No ___
- Elbows: Yes ___ No ___
- Back of the head: Yes ___ No ___
- Ears/nose: Yes ___ No ___
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Does your plan include interventions addressing nutrition and hydration?
Yes ___ No ___
4A. Does your plan include interventions to address:
- Feeding or swallowing difficulties: Yes ___ No ___
- Undernourishment (e.g., weight loss, decreased meal intake): Yes ___ No ___
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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:
- Estimation of nutritional requirements: Yes ___ No ___
- Comparison of nutrient intake with estimated requirements:Yes ___ No ___
- Recommendation for frequency of reassessment of nutritional status: Yes ___ No ___
- Weight pattern change summary: Yes ___ No ___
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Does your plan include an assessment for pain?
Yes ___ No ___
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Does your plan include an assessment for decreased mental status?
Yes ___ No ___
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Does your plan include an assessment for incontinence?
Yes ___ No ___
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Does your plan include an assessment for medical device-related pressure?
Yes ___ No ___
9A. Do recommendations for positioning include the following?
- ___ Dealing with medical devices (oxygen tubing, catheters)
- ___ Guidance for avoiding friction and shear
- ___ Support surfaces
- ___ Frequency of repositioning
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Does your plan include an assessment for friction and shear?
Yes ___ No ___
10A. Does your plan include an assessment for muscle spasms?
Yes ___ No ___
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Does your plan include an assessment for immobility?
Yes ___ No ___
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Does your plan include an assessment for contractures?
Yes ___ No ___
Section 3: Communication Practices
- 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 | No | ADON | Nursing – A Social Services – A Activities – A Rehab – V Dietitian – A |
Weekly |
b. Report or brief with CNAs | No | Nurse Manager | Nursing Assistants -A | Every shift |
c. Report or brief with department heads | No | Administrator | Department heads (Nursing, Activities, Social Service, Rehab, Dietary, Maintenance and Housekeeping) – A | Every morning |
d. Medical staff | No | N/A | N/A | N/A |
e. QAPI* or performance improvement plan meeting | Yes, if pressure ulcers are a problem | DON | Department heads and medical director – A | Quarterly |
f. Skin or wound meeting | No, unless the resident has a pressure ulcer | Wound care nurse | Nursing – A | Weekly |
g. MD/APRN* rounds | No | N/A | N/A | N/A |
h. Report or brief with Dietary Department | No | Dietitian | Dietitian and DON | Weekly |
i. Report or brief with Social Services Department | No | N/A | N/A | N/A |
j. Report or brief with Therapy Department | No | Rehab Director | Rehab Director and DON | Weekly |
k. Report or brief with "Other" |
* QAPI = Quality Assessment and Performance Improvement; APRN = advanced practice registered nurse.
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Training
Indicate the date of the most recent training provided for the following:
Topic | Participants | Date |
---|---|---|
a. Conducting an accurate skin assessment | Nurses | On hire |
b. Conducting an accurate skin assessment | CNAs | 5-10-14 |
c. Effective positioning | Nurses | On hire |
d. Effective positioning | CNAs | 5-10-14 |
e. Skin care | CNAs | 2-1-13 |
f. Documentation—meal and fluid intake | CNAs | 3-10-14 |
g. Documentation—positioning | CNAs | 3-10-14 |
Section 4: Investigations/Root Cause Analysis of Pressure Ulcer Development
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Do you investigate each new in-house pressure ulcer according to your facility's policies and guidelines?
Yes _X_ No ___ Not Sure ___
-
Do you investigate each new in-house pressure ulcer in a root cause framework?
Yes ___ No ___ Not Sure _X_ If no, stop here.
-
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?
___________________________________________________ -
In the course of your 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.
- ___ Change in condition
- ___ Weight loss
- ___ Change in meal intake
- ___ Change in fluid intake
- ___ Change in mobility
- ___ Change in continence
- ___ Change in ability to communicate pain
- Other (specify): ________________________________________________________
- ___ Other (specify): ________________________________________________________
- 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:
- ___ Nutrition assessment for a resident with decreased meal or fluid intake
- ___ Nutrition screen for a resident at risk of developing a pressure ulcer
- ___ Pain assessment
- ___ Cognitive assessment
- ___ Incontinence assessment
- ___ Medical device-related pressure assessment (e.g., oxygen tubing, catheters)
- ___ Assessment for friction and shear
- ___ Mobility assessment
- ___ Contracture assessment
- ___ Assessment for appropriate bed and chair support surfaces
- ___ Positioning assessment
- ___ Skin assessments per frequency designated by MD/NP
- ___ Other (specify): ________________________________________________________
- ___ Other (specify): ________________________________________________________
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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?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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Are there any particular obstacles or challenges to investigating the causes of pressure ulcers?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Review of the Nursing Home's Pressure Ulcer Prevention Implementation: Unscripted Exercise #2
Suggested Prompts for Facilitator
You want the team to understand what the nursing home is doing related to pressure ulcer prevention: screening, prevention practices, clinical meetings that are held that discuss pressure ulcer prevention in some way, and how they investigate new pressure ulcers. In addition, you want to identify how they identify changes in risks and how the risks get used to make care plan changes. The goal is to use the meeting as background to help them think about how to ultimately use the On-Time reports to improve the prevention of pressure ulcers in the next change team meeting.
- What do you notice about their screening practices?
- Prompts if team does not pick up on these aspects of the self-assessment.
- They do not use a standardized assessment tool and only screen for impaired mobility, incontinence, and history of pressure ulcers.
- Residents are screened for pressure ulcer risk only on admission/readmission and quarterly with MDS assessments.
- Nursing assistants complete the skin assessment/observations.
- They do not screen for pressure ulcer risk in residents with diabetes, peripheral vascular disease, nutritional deficits, contractures, or paralysis.
- How often are they reassessed?
- How is the assessment used to inform nurses and other disciplines about the need for changes in care plans?
- Prompts if team does not pick up on these aspects of the self-assessment.
- What do you notice about their prevention practices?
- They do not develop a care plan for residents at risk for developing a pressure ulcer.
- Are the appropriate disciplines being consulted when pressure ulcer risk factor interventions are suggested?
- What do you notice about the meetings they listed in the Communication table?
- Prevention is not discussed at any meeting.
- Nursing assistants do not attend any meetings except shift report.
- How could they improve multidisciplinary input to help reduce pressure ulcer risk factors? What additional meetings could be used to improve pressure ulcer prevention?
- What do you notice about their Investigations/Root Cause Analysis?
- They say they investigate new in-house pressure ulcers, but don't use a root cause framework. Root cause analysis (RCA) is a structured method for investigating serious adverse events. It involves the use of a specified protocol to analyze the circumstances leading up to the event with the goal to identify how and why the event occurred and to then make the changes necessary to prevent future adverse events.
- How could the On-Time Prevention reports help root cause analysis?
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