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

Self-Assessment Worksheet for Pressure Ulcer Prevention

The Self-Assessment Worksheet is designed to help staff review how they currently identify residents who have experienced a change in pressure ulcer risk, how they determine if new clinical interventions are needed, and how they determine what those interventions are. The self-assessment tool is intended to help identify the current processes and structures the nursing home uses to prevent pressure ulcers and identify gaps and places for improvement. It is intended to help staff think about ways to transform these processes and how to begin to use the pressure ulcer prevention reports in clinical discussions. The self-assessment tool is an important first step in implementing the reports into current workflow.

The team is expected to use the Self-Assessment Worksheet to help understand current pressure ulcer prevention practices. This is the first step to help them determine how to transform their current practices and to identify ways to incorporate the On-Time Reports into current practice. It is expected that the facilitator will work with the change team to identify gaps in current pressure ulcer prevention practices and help them see ways to incorporate the reports to improve these practices and improve clinical interventions.

The Self-Assessment Worksheet shows how the nursing home:

  • Identifies how they identify which residents are at risk of pressure ulcers.
  • Identifies how they develop interventions to prevent pressure ulcer formation.
  • Identifies how they discuss at-risk residents and formulate changes in care plans.
  • Identifies how they carry out root cause analysis when a pressure ulcer occurs.

The Self-Assessment Worksheet has four sections:

Self-Assessment Worksheet for Pressure Ulcer Prevention

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 ___ No ___ If no, skip to Question 3.
  2. If yes, does the policy include the following:
  Yes No
a. Clinical areas to be covered ___ ___
b. Timing or frequency of assessments ___ ___
c. Documentation requirements ___ ___
d. Communication to care team ___ ___
  1. Does your facility provide training to nursing staff on how to accurately assess for pressure ulcer risk?
       Yes ___ No ___
  2. Does the pressure ulcer risk assessment use a standardized assessment tool (for example, Braden score of Norton tool)?
       Yes ___ No ___ 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 ___ ___
b. Incontinence ___ ___
c. Nutritional deficits ___ ___
d. Diabetes diagnosis ___ ___
e. Peripheral vascular disease diagnosis ___ ___
f. Contractures ___ ___
g. History of pressure ulcers ___ ___
h. Paralysis ___ ___
  1. How frequently is the risk assessment tool completed?
    1. ___ Monthly
    2. ___ Quarterly
    3. ___ Annually
    4. ___ Change of condition
    5. ___ Other (specify): ______________________________________________________
  2. When are residents screened for pressure ulcer risk? Check all that apply.
    1. ___ Upon admission/readmission
    2. ___ With a change in condition
    3. ___ 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 ___ 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.
  4. Who completes the skin assessment/inspection on admission?
    1. ___ Admitting nurse
    2. ___ 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. ___ Nursing assistant
    3. ___ Wound care nurse
    4. ___ Other (specify): _____________________________________________________
  6. How often are skin assessments/inspections completed?
    1. ___ Daily
    2. ___ Weekly
    3. ___ Monthly
    4. ___ Other (specify): _____________________________________________________
  7. Where are skin assessments/inspections documented?
    1. ___ Medical record
    2. ___ Nursing assistant documentation
    3. ___ Skin assessment form
    4. ___ Other (specify):_____________________________________________________
  8. Do you screen all residents for pressure ulcer risk at the following times:
    1. Upon admission                                    Yes ___ No ___
    2. Upon readmission/reentry                     Yes ___ No ___
    3. When there is a change in condition       Yes ___ No ___
    4. With each MDS assessment                    Yes ___ No ___
  9. If the resident is not currently deemed at risk, is there a plan to rescreen at regular intervals?
    Yes ___ No ___
  10. Do you screen residents for pressure ulcer risk with the following diagnoses?
    1.  Diabetes mellitus                    Yes ___ No ___
    2. Peripheral vascular disease   Yes ___ No ___
    3. History of pressure ulcer        Yes ___ No ___
    4. Paralysis                                 Yes ___ 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.

  1. Do you develop a care plan for residents at risk of developing a pressure ulcer?
    Yes ___ No ___ 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 ___ 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 ___ No ___ Not Sure ___
  2. Do you investigate each new in-house pressure ulcer in a root cause framework?
    Yes ___ No ___ Not Sure ___ 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?



Return to Pressure Ulcer Prevention

Page last reviewed December 2017
Page originally created March 2013
Internet Citation: AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/pruprev/saworksheet.html