Long-Term Care Survey Alert

Prevent decubs and F314 tags -- and save staffing time.

You probably already have a turning and repositioning program for residents who need it in bed. But what about residents who spend hours sitting in wheelchairs?

The survey reality: The revised F314 survey guidance discusses how residents at risk for skin breakdown can develop pressure ulcers from sitting too long on a static surface.

The problem: "Sometimes care staff don't think about how sitting upright in a wheelchair can pose a risk of skin breakdown," observes Janet Gowen, RN, MSN, education coordinator for Frazier Rehab Institute in Louisville, KY.

Smart move: Identify residents in wheelchairs at high risk for developing a pressure ulcer -- that is, those who trigger on the pressure ulcer resident assessment protocol (RAP) or have a designated score on the Braden scale or other standardized risk assessment. Then implement a program that enlists residents' help in giving themselves a "pressure break."

Conduct Performance Tests

Do a performance evaluation to see if a resident can stand up from the wheelchair on his own if verbally prompted to do so. Barbara Bates-Jensen, PhD, RN, CWOCN, reports doing a study to that effect where researchers placed a chair a short distance in front of the person sitting in the wheelchair.

The researcher then gave the person a verbal command: "Please stand up," explains Bates-Jensen, an adjunct assistant professor with the UCLA

School of Medicine and VA Greater Los Angeles Healthcare System in Sepulveda, CA.

Take the Next Step

If the verbal cues don't work, provide actual hands-on guidance to see if people can stand up and bear their own weight, suggests Bates-Jensen.

Of course, "even though the person may be able to stand up and bear weight, he may be unstable on his feet and not necessarily safe in doing it without assistance," she adds. "But the performance test does identify people who can stand up and bear their weight" so that staff can either verbally cue the person to do so -- or assist him to stand up.

Teach Residents These Exercises

Wheelchair-bound residents with lower paralysis due to spinal cord injury or other causes can learn some simple maneuvers to take pressure off their ischial tuberosities.

For example, the person can "hook her arm under the wheelchair push handle and do 'lean overs,'" says Gowen. The person leans "left to right"every 15 to 20 minutes, she says.

The person can also "lean forward by resting his forearms on his thighs -- or do wheelchair push-ups to raise his bottom from the chair." If the person can't safely perform the maneuvers, the nursing staff can help him, says Gowen.

Care plan it: The care plan should direct staff to cue or assist residents to stand up and/or do the pressure-relieving maneuvers at designated intervals, depending on the person's risk profile and skin condition.

Implement Reminder Systems

If the resident can't remember to do the weight-shifting exercise on his own, you can devise various prompts.

For example, the person can use an alarm on his wristwatch set to go off at designated intervals while he's sitting in the chair, says Cheryl Field, MSN, RN, a certified rehabilitation nurse and consultant with LTCQ Inc. in Lexington, MA.

Or remind the person to reposition during each commercial break as he watches television.

Get Physical Therapy, Restorative With the Program

Traditionally, the physical therapist assesses the person's "upper body strength and trunk stability" and teaches her techniques for relieving pressure while sitting, says Field. In addition, "wheel chair repositioning can be a valuable restorative program."

MDS coding tip: Code the program on the MDS at P3k (other restorative programs) in cases where the resident does five minutes of repositioning exercises at least three times a day as part of a restorative program that meets the RAI manual criteria for coding it, advises Field. (Review the criteria on pp. 3-191 through 3-197 of the RAI manual at www.cms.hhs.gov/NursingHomeQualityInits/20_NHQIMDS20.asp#TopOfPage.)

As part of the repositioning program, the restorative staff should be present to "observe, cue, encourage, provide feedback, and document [the resident's] response and improvement," says Field.