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

Functional Specifications (continued)

3. Specifications for Each Pressure Ulcer Prevention Report

3.1. Nutrition Risk Reports: High Risk and Medium Risk

3.1.1. Report Description

The weekly reports display resident-level nutrition information for a single nursing unit: average weekly meal intake for 4 consecutive weeks, diet, tube feeding status, average supplement intake for the report week, and recent weight change. The reports sort residents into high and medium nutritional risk; two separate reports are generated.

The reports use two criteria to determine level of nutritional risk; residents meeting one or both criteria will display on either the high or medium risk report, never both.

Risk criteria follow:

  • If meal consumption is 50 percent or less for two meals in one day at least one time during the report week.
  • If there is any weight loss during the report week, determined by subtracting current week’s weight from most recent weight.

Criteria and Level of Risk for Nutrition Risk Reports

Nutrition Risk Report Nutrition Risk Criteria
Decreased Meal Intake Weight Loss
Medium Risk Report*  
Medium Risk Report  
High Risk Report

* Residents at high and medium risk display on separate reports.

3.1.2. Dependencies and Clinical Assumptions

3.1.2.1. Electronic daily documentation by CNA staff is required for the following:

  • Meal intake.
  • Bowel.
  • Bladder.
  • ADL assistance needed and support provided for bed mobility, transfer, locomotion, dressing, personal hygiene, toileting, and bathing.

3.1.2.2. Meal intake is recorded for 3 meals each day for each resident; thus, documentation of 21 meals is required for each resident each week.

3.1.2.3. Physician order entry is required for the following:

  • Diet order.
  • Supplement order.
  • Tube feeding order.

3.1.2.4. A resident may have a diet order and an order for tube feeding.

3.1.2.5. Percentages of supplement intake are recorded in the system.

3.1.2.6. Notes regarding resident weights:

  • Resident weights may be obtained monthly, weekly, daily, or more often, such as dialysis weights, which may be pre- and postdialysis treatments; the frequencies to obtain resident weights vary by facility.
  • All weight values for a resident are associated with a weight date.
  • The system stores a weekly weight for each resident. If multiple weights are taken in one static week, then use the lowest weight as the "weekly weight."
  • A resident must have a weight date within the report week to compute a weight change; if no weight value is stored for the report week, then weight change fields are BLANK.

3.1.3. Report Example: Nutrition High-Risk Report

3.1.3.1. Report Inclusion Criteria 

In the sample Nutrition Risk Report below, residents are at high risk because they met both risk criteria:

  • If meal consumption is 50 percent or less for two meals in one day at least one time during the report week as evidenced by a date value in the "Decreased Intake: first date" column for each resident; and
  • If there is any weight loss during the report week, determined by subtracting current week’s weight from most recent prior weight as evidenced by a negative value in the "Weight Change lbs" column for each resident.
  • In addition, if the resident is Tube Fed and has weight loss during the report week, the resident will display on the Nutrition Report: High Risk.
Resident Room 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 / Order Date Tube Feed Avg Supplement Intake %* Weight Change (lbs) 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    

 

3.1.4. Report Example: Nutrition Medium Risk Report

3.1.4.1. Report Inclusion Criteria

In the sample Nutrition Risk Report below, residents are at medium risk because they met one of the two risk criteria:

  • If meal consumption is 50 percent or less for two meals in one day at least one time during the report week as evidenced by a date value in the "Decreased Intake: first date" column for residents E and G.
  • If there is any weight loss during the report week, determined by subtracting current week’s weight from most recent prior weight as evidenced by a negative value in the "Weight Change lbs" column for residents F and H.
  • In addition, if a resident is tube fed (no weight loss) during the report week, the resident will display on the Nutrition Report: Medium Risk.
Resident Room 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/Order Date Tube Feed Avg Supplement Intake %* Weight Change (lbs) Most Recent Ulcer Assess Date # Pr Ulcers
A 008 03/16/2014 85 83 75 66 Pureed
2/28/14
X        
B 009   85 85 86 88 Mech
1/22/14
X 50% -3.1    
C 011 03/19/2014 55 37 61 35 Reg
3/22/14
X     3/20/14 1
D 016   51 61 71 64 Reg
12/3/13
X   -2.5    

 

3.1.5. Valid Input, Calculations, and Displays

3.1.5.1. Resident risk for high or medium risk should be determined for all residents for the report week and the appropriate nutrition risk flag set to TRUE (either high or medium nutrition risk) if criteria are met. Residents at nutrition risk display on other On-Time reports where data are displayed for the current and prior 3 weeks. Assigning nutrition risk flags to residents who meet high or medium risk criteria eliminates the need to recalculate nutrition risk levels for each resident for reports where these values display.

3.1.5.2. The system must have the ability to assign a unique ID to each pressure ulcer for a single resident.

Nutrition Risk Reports Specifications

Report Column Data Source Valid Input & Display
Decreased Meal Intake CNA documentation of meal intake Dates of the current week the resident had meal intake of 50% or less for two meals in one day.
Note: A week is defined as a static week, for example, starting every Sunday through Saturday or Monday through Sunday. Use the facility’s preferred static week parameters.
The facility or vendor may choose to display all dates when decreased meal intake occurred during a given week; if so, separate multiple decreased intake dates with semicolons.
Average Meal Intake % Week CNA documentation of meal intake Calculate meal averages for residents having at least 75% meal intake documentation completed. Numerator: The meal intake (includes breakfast, lunch, dinner) percentage for each meal (sum of meal % for the week) for each week of the 4 weeks prior to report ending date.
Denominator: The total possible meals in one week. If a resident is available for each meal, then the denominator = 21.
Average Meal Intake:
3 Prior Weeks (Weeks 4, 3, and 2):

  • Report uses a static week, Monday through Sunday (confirm facility parameters for static week) for 3 prior weeks.

Current Week (Week1)
Average meal intake for current week is computed using information available up to report generation date. Display meal average percentage using total possible meals as denominator. E.g., if assessment due day = Thursday, then total possible meals through Wednesday = 9.
Meal Intake documentation options:

  • Meal intake percentage: If meal intake is documented in ranges, then the middle of the range should be the value used in the average calculation. For example, if a range is 51-75%, the percent value used would be 63%.
  • Refused meal: If an option of Refused Meal is entered, the value used in the average calculation is zero.
  • If meal is tube fed, the value used in the average calculation is zero.
  • NPO: If an option of NPO is entered, the value used in the average calculation is zero. NPO is an order to withhold oral food and fluids.
  • Unavailable for meal: if the resident is not present for a meal, then this option is selected. If a resident is unavailable for a meal, such as out on pass, or otherwise not present during mealtime, then the entry should be counted as complete documentation for the meal. But it does not contribute a value to the average meal intake (numerator), and the denominator is reduced by one for each occurrence during the report week.
  • Missing meal intake value: if there is no entry in the breakfast, lunch, or dinner meal intake field, then no value contributes to the average meal calculation.
Diet / Order Date Physician Orders If there is a physician order for a diet, then display the Diet name and the date that it was ordered. If there is no physician order for a diet, then leave the cell BLANK.
If the resident has an order for NPO and the NPO order date is more recent than the diet order, then display NPO and the date of the NPO order instead of the diet name and diet order date.
Note: A physician order for NPO should cancel out or discontinue the prior diet order; likewise, when the physician orders a diet after the NPO order date, then the NPO status is discontinued.
Tube Feeding (TF) Physician Orders If there is a physician order for tube feeding, then display an X. If there is no physician order for tube feeding, then leave the cell BLANK.
If the EMR system does not capture physician orders, then the vendor must determine the best source for determining the presence or absence of tube feeding for a resident, which could be nurse / nursing assistant documentation.
Average Supplement Intake % Nurse documentation of supplement intake percentages If there is a physician order for supplements, then calculate average supplement intake. If there is no physician order, then leave the cell BLANK.
Numerator: Average of all supplement intakes for the report week.
Denominator: Use supplement order frequency for denominator. If order frequency is once daily, then denominator = 7; twice daily, then denominator = 14; etc. If supplement frequency is PRN, then do not calculate average supplement intake percentage and leave cell BLANK.
Display as percentage.
Weight Change (lbs) Vital Signs or Weight documentation If the resident does not have a weight value stored in the system for the current report week, then do not calculate a weight change and leave cell BLANK.
If multiple weights are taken in one week, the lowest weight is used as the Weekly Weight.
Weight change (lbs) calculation:
(Most Recent Weight − Previous Weight).
Display weight change as + for weight gain and − for weight loss.
Most Recent Weight must occur during the current week.
The Previous Weight is the next most recent lowest weekly weight within the last 200 days. The Previous Weight does not need to occur in the week just prior to the current week. Often residents are on monthly weights, so the Previous Weight may be 4 weeks prior to the Current Weight.
Most Recent Ulcer Assessment Date Nurse documentation of pressure ulcer assessment If nurses are not documenting pressure ulcer assessments in the EMR, then leave cell BLANK. The EMR vendor has the option to remove the column from the report display.
If nurses are documenting pressure ulcer assessments in the EMR, then display the date of most recent pressure ulcer assessment. If there are two assessments in the prior week, then use the assessment having a date closest and prior to the report date.
# Pressure Ulcers Nurse documentation of pressure ulcer assessment Count the number of unique ulcers for the resident and display the count.
Do not count ulcers that are considered inactive or healed.

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Page last reviewed April 2016
Page originally created September 2014
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. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/pruprev/pruprev-functspecs3.html