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Pressure Injuries

Pressure injury prevention and documentation: Best practices in skilled nursing settings

Find out some of wound specialist Amy Bruggemann's top tips for preventing pressure injuries and ulcers developing in long term care settings. Also find out how documentation can help you avoid getting cited with an avoidable pressure ulcer.

Accora’s recent webinar was all about how to prevent pressure injuries occurring in long-term care and SNF settings, and also about producing effective documentation which supports that any pressure ulcers that did develop or worsen in your facility were unavoidable.

This short article will cover some of the key points touched on by our wounds specialist from Specialized Wound Management, Amy Bruggemann MSN, APRN-BC, CWS for the purpose of bite-sized wound prevention, pressure management, and compliance education.

Why are pressure ulcers so common in nursing homes?

Before we look at the practical ways we can prevent pressure injuries and the resulting ulcers, we need to think about why pressure injuries are such a problem right now.

According to Amy Bruggemann, the SNF population is “not the same population that it was 25 or 30 years ago. What we’re finding, especially post-covid, is that the patients that were in the SNF facility are now in an assisted living facility. Your assisted living patients are now in independent living. Your independent patients are still out living in the community. The illnesses are much more acute than they’ve ever been before.”

We all know that the cases we see now in long-term care have increasingly complex needs than we’ve seen historically, but what does that have to do with the breakdown of skin specifically?

Amy Bruggemann explains, “The skin is our largest organ. If the body is in flux, the body is going to take all energy and bring it to the core [to support] major organs: heart lungs, kidneys, bladder. We cannot function if our hearts and lungs are not functioning correctly. So, the body will pull from the biggest organ (our skin) which is where we keep our reserves. The patients are just more medically complex than they’ve ever been before.”

With that in mind, it’s easy to understand why pressure ulcers do develop in SNF settings where people are often recovering from severe illnesses or surgeries but it’s also important to note that this problem is only going to grow as boomers continue to enter senior care communities and the population continues to age. The increasing risk of pressure ulcers and establishing good skin care practices to prevent them are only going to become more important for long-term care communities in the next years.

What constitutes a PI to be deemed unavoidable?

Understanding what the F-686 citation says about whether a pressure injury that was obtained/worsened whilst being cared for in your facility was avoidable or not is key to putting appropriate interventions in place and documenting effectively. Ideally, there would be zero pressure injuries in your building at all, but let’s be realistic, PIs happen because it’s hard to continuously fight with gravity.

The F-686 CMS regulation requires that a resident who is admitted without a pressure ulcer doesn’t develop a pressure ulcer, or if they are admitted with one, it will not decline unless it is clinically unavoidable. In layman's terms: Don’t get caught with a new pressure ulcer in your building unless you have documentation to prove it couldn’t have been avoided. But here’s the kicker: a pressure ulcer and a pressure injury are not exactly the same thing.

A pressure ulcer, sometimes known as a bed sore or decubitus ulcer, is the eventual result of a pressure injury, and the ulcer (the open wound) may not be visible for some time after the injury occurred. Sometimes it takes several days for the dead tissue to work its way out to the surface or even to become visible at all, especially in the case of deep tissue injuries. That’s why interventions must be in place and properly documented almost before an injury could occur to cover yourself. That’s the tricky part: proving that we had appropriate preventive interventions in place before we even knew there was a problem. Essentially if a pressure ulcer is acquired or declines on our watch, it could create a citation and potentially cost the facility. Your clinical judgment as to whether it was avoidable or not is no longer enough. You must prove it with documentation.

Documentation to support the unavoidable status

Making sure your documentation is supporting your pressure ulcer prevention program and providing proof of your efforts and clinical decisions around each person’s care is vital to a successful survey. Oftentimes we make the changes we think are necessary for immediate comfort or relief but don’t write down that we’ve done it. Every single time a resident experiences a medical change of any kind, we need to get into the habit of asking ourselves how that could conceivably affect their skin resilience and record it. Also, record what you did (if it was appropriate to do anything) to prevent it from affecting their skin.

One thing that is often overlooked as a pressure risk is the development of a urinary tract infection. This is because a UTI affects the pH of the urine, and it can also result in dehydration. Both of these factors can affect skin integrity and cause tissue damage in a resident who may not have even been on your pressure ulcer risk radar, so every small change needs to be assessed as a potential skin breakdown risk for the successful management of pressure ulcers.

Amy Bruggemann’s experience indicates that “when the state surveyors come in if you have skin and wound issues in your building, it’s going to open you up to an entire can of other worms. If you have pressure ulcers in your building, what is the state surveyor going to think? You probably have problems with turning and repositioning. You probably have problems with incontinence care. You probably have problems with your nutrition.”

So, getting cited for avoidable pressure ulcers can set off a chain reaction of inquiry into other areas of care and nobody wants that. How do you avoid it? It all starts with a pressure ulcer risk assessment. 

When to document

So, when should you be evaluating or re-evaluating your pressure management strategy? Every time there is a change for that person but most particularly when any of the following occurs:

New admission – When a resident is admitted to your building you need to evaluate their skin and risk factors.

Acute illness – Any exacerbation of an acute illness or the development of a new one needs to be assessed for the potential risk of skin breakdown.

Chronic illness – Again, any development or exacerbation of a chronic illness needs consideration.

Non-compliance – When a resident refuses to follow the advice which could prevent pressure injuries, you need to assess if different interventions need to be prescribed but also to document the refusals.

New admissions, changes in acute or chronic illnesses or non-complaince should all result in a reassessment of skin breakdown risk

Managing and understanding pressure risk factors

Generally speaking, the most common time for a newly admitted resident to develop a pressure ulcer is between two to four weeks after admission. You might expect that it would be sooner than this but while the person is transitioning and adjusting to life within a SNF setting, they tend to get a lot of attention and visits from the various specialists. They also probably get frequent visits from their family members, and this means there are more opportunities for someone to spot pressure-related discomfort or assess risks for that person. That tends to change after two weeks or so as they settle in.

Amy Bruggemann suggests that when new admits come to a care community, they are probably coming from an acute setting either because of surgery or another medical condition. “By the time they come to us, we’re generally two weeks in this illness. Everybody’s coming by. Chances are the PTs and OTs are coming in, setting up their plan of care. Then we’ve got the CTAs and OTAs, and we’ve got dietary stopping by, social services is stopping by, and activities. Everyone’s checking in on them. After they’ve been there a couple of weeks everybody takes a deep breather. Even the patient might take a deep breather. They’re exhausted. They spend a little bit more time in bed than they did before. So, what happens is we start to see these skin ulcers show up.”

The sad truth is that despite our best efforts and interventions put in place, we may not be able to achieve the clinical outcomes that we, the resident, or their loved ones would want. Pressure ulcers happen, but the CMS guidance ensures that we can’t just accept that as care professionals, and rightly so. If we possibly can prevent pressure injuries, then we should make every effort to do so and document it to support the unavoidable status should the worst-case scenario happen.

It’s also vital for long-term caregivers to keep stakeholders in the loop about developments and interventions at every step. This is crucial for effectively managing the expectations of their loved ones so they can see the various actions and interventions that were taken prior to an unavoidable pressure wound showing up. Keeping them updated from the initial suspicion of risk through every intervention and outcome will let the family know that you did everything right versus getting what they perceive as a phone call out of the blue saying, “Your mom has a bed sore”. In one scenario they feel like their loved one was let down by your facility and in the other they’ll likely agree that you did everything you could to prevent it.

Final thoughts

When managing pressure risk in a long-term care setting, all actions taken should be equally supportive of the resident’s quality of life and supportive of a smooth future survey. Of course, it's your job as a healthcare provider to help the person now in every way you can whether it’s management or prevention of a wound, but it's also vital to protect yourself and your facility for the future by documenting it.

Amy’s key points to take away from the webinar were not to wait to intervene when a risk is identified or develops and to keep channels of communication open, both internally in your facility and externally with their support network.

If you’d like to hear more of Amy Bruggemann’s expert advice for caregivers and nursing professionals on preventative care and management of pressure ulcers then you can watch the full webinar on-demand here.

Pressure Injuries
Long Term Care
Accora Team
FloorBed technology to help skilled nursing, rehabilitation and long term-care facilities prevent falls and fall-related injuries.
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