By David Hoffman
From Compliance Today, a publication for HCCA members
I have spent much of my career focused on pressure ulcers, since avoidable pressure ulcers have served as the basis for successful government enforcement activities. I believe that compliance officers in hospitals and nursing homes must be cognizant of the need for nursing staff to use their judgment in determining a patient’s risk for developing pressure ulcers. Concluding that a patient is at mild risk or not at risk at all, despite having an actual pressure ulcer, is an indicator that nurses may be focusing on the questions on the often-used Braden Scale without using their skills to make accurate and appropriate risk assessments. Facilities that use wound care policies and procedures based upon the Braden Scale score may find an absence or a delay in the implementation of these procedures, if the Braden Scale score is calculated inappropriately or if the assessment of the patient is not taken into consideration in determining an individual’s specific risk for the development of pressure ulcers. The following interventions should be considered:
- Conduct audits on current patients throughout the facility with staff nurses by reviewing patients’ current Braden Scale scores, their current clinical condition, and the interventions in place. Is there a discrepancy between what the Braden Scale score predicts and the measures put into place? Is there a discrepancy between what measures are in place and the policies and procedures for pressure ulcer prevention or treatment?
- Does the Braden Scale score dictate the implementation of specific policies in terms of support surfaces (beds), dietary consultations, and topical treatments? Is the staff aware of what Braden Scale score places a patient at high risk?
- Are there sufficient numbers of support surfaces in-house or available by contract to meet the needs of the patients? Is there a process in place that assures relative easy access to appropriate mattresses and beds?
- Do house officers, hospitalists, and attending physicians read and act upon the recommendations of the dietitian, the wound care team, and others involved in pressure ulcer treatment and prevention? Do physicians defer to nursing for all wound assessments as well as recommendations for care? Who is ultimately responsible for the coordination of wound treatment plans in the hospital?
- Perform an audit of patients who developed Stage II, III, IV, unstageable, and suspected deep tissue injury (SDTI) wounds during the course of their hospitalization or nursing home stay. Did the patients’ Braden Scale scores predict these wounds? If not, is there an opportunity to improve staff education to ensure understanding of the process of determining a Braden Scale score as well as the application of nursing judgment to fully appreciate those patients at risk?
The accurate reporting of hospital and nursing home-acquired pressure ulcers and effective pressure ulcer prevention and treatment protocols are important quality and compliance issues that must be incorporated into a facility’s effective compliance program.
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