F Tag 314 309 Quality of Care Part 7 Pressure Ulcer Investigative Protocol
- INVESTIGATIVE PROTOCOL part 7 PRESSURE ULCER; Objectives:
To determine if the identified pressure ulcer(s) is avoidable or unavoidable; and To determine the adequacy of the facility’s interventions and efforts to prevent and treat pressure ulcers.
- Use this protocol for a sampled resident having—or at risk of developing— a pressure ulcer. If the resident has an ulcer, determine if it was identified as non-pressure related, e.g., vascular insufficiency or a neuropathic ulcer. If record review, staff and/or physician interview, and observation (unless the dressing protocol precludes observing the wound) support the conclusion that the ulcer is not pressure related, do not proceed with this protocol unless the resident is at risk for developing, or also has, pressure ulcers. Evaluate care and services regarding non-pressure related ulcers at F309, Quality of Care.
Briefly review the assessment, care plan and orders to identify facility interventions and to guide observations to be made. For a newly admitted resident either at risk or with a pressure ulcer, the staff is expected to assess and provide appropriate care from the day of admission. Corroborate observations by interview and record review.
Observe whether staff consistently implements the care plan over time and across various shifts. During observations of the interventions, note and/or follow up on deviations from the care plan as well as potential negative outcomes, including but not limited to the following:
– Erythema or color changes on areas such as the sacrum, buttocks, trochanters, posterior thigh, popliteal area, or heels when moved off an area:
– If erythema or color change are noted, return approximately ½ – ¾ hours later to determine if the changes or other Stage I characteristics persist;
– If the changes persist and exhibit tenderness, hardness, or alteration in temperature from surrounding skin, ask staff how they determine repositioning schedules and how they evaluate and address a potential Stage I pressure ulcer;
– Previously unidentified open areas;
– Whether the positioning avoids pressure on an existing pressure ulcer(s);
– Measures taken to prevent or reduce the potential for shearing or friction during transfers, elevation, and repositioning; and
– Whether pressure-redistributing devices for the bed and/or chair, such as geltype surfaces or overlays are in place, working, and used according to the manufacturer’s recommendations.
- Observation of Existing Ulcer/Wound Care
If a dressing change is scheduled during the survey, observe the wound care to determine if the record reflects the current status of the ulcer(s) and note:
– Characteristics of the wound and surrounding tissues such as presence of granulation tissue, the Stage, presence of exudates, necrotic tissue such as eschar or slough, or evidence of erythema or swelling around the wound;
– The form or type of debridement, if used;
– Whether treatment and infection control practices reflect current standards of practice; and
– Based on location, steps taken to cleanse and protect the wound from likely contamination by urine or fecal incontinence.
If unable to observe the dressing change due to the dressing protocol, observe the area surrounding the ulcer(s). For ulcers with dressings that are not scheduled to be changed, the surveyor may request that the dressing be removed to observe the wound and surrounding area if other information suggests a possible treatment or assessment problem. If the resident expresses (or appears to be in) pain related to the ulcer or treatment, determine if the facility:
– Assessed for pain related to the ulcer, addressed and monitored interventions for effectiveness; and/or
– Assessed and took preemptive measures for pain related to dressing changes or other treatments, such as debridement/irrigations, and monitored for effectiveness.2.
- Resident/Staff Interviews
Interview the resident, family or responsible party to the degree possible to identify:
– Involvement in care plan, choices, goals, and if interventions reflect preferences;
– Awareness of approaches, such as pressure redistribution devices or equipment, turning/repositioning, weight shifting to prevent or address pressure ulcer(s);
– Presence of pain, if any, and how it is managed;
– If treatment(s) was refused, whether counseling on alternatives, consequences, and/or other interventions was offered; and
– Awareness of current or history of an ulcer(s). For the resident who has or has had a pressure ulcer, identify, as possible, whether acute illness, weight loss or other condition changes occurred prior to developing the ulcer.
Interview staff on various shifts to determine:
– Knowledge of prevention and treatment, including facility-specific guidelines/protocols and specific interventions for the resident;
– If nursing assistants know what, when, and to whom to report changes in skin condition; and
– Who monitors for the implementation of the care plan, changes in the skin, the development of pressure ulcers, and the frequency of review and evaluation of an ulcer.3.
- Record Review Assessment
Review the RAI and other documents such as physician orders, progress notes, nurses’ notes, pharmacy or dietary notes regarding the assessment of the resident’s overall condition, risk factors and presence of a pressure ulcer(s) to determine if the facility identified the resident at risk and evaluated the factors placing the resident at risk:
– For a resident who was admitted with an ulcer or who developed one within 1 to 2 days, review the admission documentation regarding the wound site and characteristics at the time of admission, the possibility of underlying tissue damage because of immobility or illness prior to admission, skin condition on or within a day of admission, history of impaired nutrition; and history of previous pressure ulcers; and
– For a resident who subsequently developed or has an existing pressure ulcer, review documentation regarding the wound site, characteristics, progress and complications including reassessment if there were no signs of progression towards healing within 2 to 4 weeks. In considering the appropriateness of a facility’s response to the presence, progression, or deterioration of a pressure ulcer, take into account the resident’s condition, complications, time needed to determine the effectiveness of a treatment, and the facility’s efforts, where possible, to remove, modify, or stabilize the risk factors and underlying causal factors.
- Care Plan
For the resident at risk for developing or who has a pressure ulcer, determine if the facility developed an individualized care plan that addresses prevention, care and treatment of any existing pressure ulcers, including specific interventions, measurable objectives and approximate time frames.
If the facility’s care of a specific resident refers to a treatment protocol that contains details of the treatment regimen, the care plan should refer to that protocol. The care plan should clarify any major deviations from, or revisions to, that protocol in a specific resident. A specific care plan intervention for risk of pressure ulcers is not needed if other components of the care plan address related risks adequately. For example, the risk of skin breakdown posed by fecal/urinary incontinence might be addressed in that part of the care plan that deals with incontinence management. If the resident refuses or resists staff interventions to reduce risk or treat existing pressure ulcers, determine if the care plan reflects efforts to seek alternatives to address the needs identified in the assessment.
- Revision of the Care Plan
Determine if the staff have been monitoring the resident’s response to interventions for prevention and/or treatment and have evaluated and revised the care plan based on the resident’s response, outcomes, and needs. Review the record and interview staff for information and/or evidence that:
– Continuing the current approaches meets the resident’s needs, if the resident has experienced recurring pressure ulcers or lack of progression toward healing and staff did not revise the care plan; and
– The care plan was revised to modify the prevention strategies and to address the presence and treatment of a newly developed pressure ulcer, for the resident who acquired a new ulcer.4.
- Interviews with Health Care Practitioners and Professionals
If the interventions defined or care provided appear not to be consistent with recognized standards of practice, interview one or more health care practitioners and professionals as necessary (e.g., physician, charge nurse, director of nursing) who, by virtue of training and knowledge of the resident, should be able to provide information about the causes, treatment and evaluation of the resident’s condition or problem. Depending on the issue, ask about:
– How it was determined that chosen interventions were appropriate;
– Risks identified for which there were no interventions;
– Changes in condition that may justify additional or different interventions; or
– How they validated the effectiveness of current interventions.
If the attending physician is unavailable, interview the medical director, as appropriate.