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Long-Term Care Survey Alert

Abuse Investigations:

Every Wound Tells A Story ... Make Sure It's Not One Of Abuse

Published on Sat Mar 26, 2005

Hint: A picture is worth a thousand words in sizing up wounds.

Ferreting out benign bruises from those that signal potential abuse can be difficult, but the heat is on for facilities to make a best-practice effort to do so.

Start by knowing what the facility should report to the state survey  agency within 24 hours as an "injury of unknown source," based on the Centers for Medicare & Medicaid Services' definition.  According to a recent CMS clarification, the injury must meet the following criteria:

  • "The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and

  • The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time."

    The agency issued the directions in a memo to state survey agencies (S&C 05-09) available at     www.cms.hhs.gov/medicaid/surveycer/sc0509.pdf.

    "Facilities have to report suspicious injuries of unknown origin [within 24 hours] even if they can't get through the analysis of whether to report the injury," noted Janet Feldkamp, RN, BSN, LNHA, JD, speaking at the February 2005 American Health Lawyers Association "Long Term Care and the Law" conference in San Diego.

    Pics Speak a Thousand Words

    Photographically document residents' bruises and injuries of unknown source, suggests Daniel Sheridan, PhD, RN. Sheridan is a forensic nurse specialist at Johns Hopkins School of Nursing in Baltimore who has done training for surveyors on forensic wound identification. Without the pictures, a facility can lose track of bruises, even if they use little flow sheets, he cautions.

    "The [initial] photo and a series of photos will show healing," he says. "And a picture can show that you're really looking at a newer bruise than staff originally believed because a photo taken 10 hours later may show the bruise has grown," he says. Initially an injury may cause localized redness and tenderness, but over 24 hours, the area grows more black and blue, Sheridan says.

    Medical photos not only narrow the window for identifying when an injury occurred - they can identify potential patterns of unexplained bruising or injuries.

    "You can get an idea of what time of the day or night the bruises tend to appear and identify who works on those shifts," says Sheridan. Or the facility may identify a training deficit where staff need to learn better positioning and care techniques (see "Stop Unintentional Resident Injuries In Their Tracks" in the March 2005 Long-Term Care Survey Alert).

    Beware bruises in certain locations on the resident's body. "For example, bruises on the inside of the residents' thighs may signal someone is being too rough in performing pericare," says Sheridan. Or such bruising could be a sign of a sexual assault, he cautions.

    Ultrasound Technology Can Help

    New high-frequency portable ultrasound scans used to assess  patterns of edema signaling pressure-induced damage under the  skin can also give providers an inside look at the cause of a bruise of unknown source.

    Example: Little Flower Manor, which uses ultrasound as part of its skin care program, finds the scans help identify a bruising injury's potential cause.

    "We use the scan for assessing bruises to show if there's significant trauma under the skin" signaling potential abuse, says Nancy DeFranco, RN, director of nursing for the Wilkes Barre, PA nursing home. The scans can also identify the shape of what may have caused an injury in some cases. "For example, one resident had a bruise at bed-height on the shin, and the scan actually showed fluid [under the skin] in the shape of the bed frame," says DeFranco.

    "We can use the ultrasound to identify bruises that were caused by needle sticks, too," she adds.

    For more information on Little Flower Manor's use of the new ultrasound technology to improve skin care outcomes, see the case study below.

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