Long-Term Care Survey Alert

4-part plan keeps your survey record clear when residents develop decubiti.

Rule one for preventing pressure ulcers: Identify each resident's risks in real time. The second, third, and fourth rules? Care plan, care plan, care plan.

Some facilities "use a proactive approach" where they provide all non-ambulatory residents "a baseline level of preventive offloading on their beds" at admission, says Peggy Dotson, RN, principal of Healthcare Reimbursement & Strategy in Yardley, PA. "Then the residents receive additional preventive interventions based on their Braden or Norton Scale scores," she notes.

Consider these four additional strategies to keep your pressure ulcer preventive program on track:

1. Address any risk factor identified by the Braden or Norton Scale assessment even if the resident has an overall low-risk score. The care plan should address any identified risk factor whether it's with nutrition, sensory perception, mobility, moisture on the skin, etc., regardless of the overall score, says Rena Shephard, RN, MHA, FACDONA, a consultant with RRS Healthcare Consulting in San Diego.

Remember: The Norton Scale includes physical condition, mental state, activity, mobility and incontinence. The Braden Scale looks at sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

Smart move: "Customize preventive interventions" to the subscales with the lowest scores first, advised Elizabeth Ayello, PhD, RN, FAPWCA, in a Centers for Medicare & Medicaid Services-sponsored Webcast on pressure ulcers. That way you can address the person's most critical areas of pressure ulcer risk--and help conserve resources, Ayello noted.

2. Identify residents with potential "protein energy malnutrition" so you can target the problem with  nutritional interventions. Residents may have isolated vitamin or mineral deficits. But protein energy malnutrition is the condition you should be most concerned about, according to CMS Webcast presenter Dan Berlowitz MD, MPH, past president of the National Pressure Ulcer Advisory Panel. It occurs when the person's intake of calories and protein can't meet his metabolic demands, he said.

The imbalance may occur if the resident doesn't eat enough food or can't absorb nutrients. Or a person's illness--such as cancer, a new bacterial infection, COPD, chronic heart failure, etc.--escalates energy demands and triggers a cascade of hormonal and immune system changes that causes anorexia and malabsorption. And that leads to more malnutrition, as Berlowitz explained during the Webcast.

Watch out for stroke patients: Post-stroke is associated with a 30 percent rate of protein energy malnutrition, said Berlowtiz.

To detect the nutritional problem, look at the resident's body-mass index, or BMI (weight in kilograms divided by height in meters squared). "A BMI below 22 is often cause for concern," said Berlowitz, noting that you need to interpret BMI within the context of recent weight loss.

Consider doing this test: A prealbumin test, which looks at the person's visceral protein stores, may be more sensitive to recent changes in the resident's nutritional status than an albumin test, he added.

Tip: Calculate a resident's BMI online at http://nhlbisupport.com/bmi.

3. Augment standardized pressure ulcer assessments with additional data collection. For example, look at the resident's medications, such as psychoactive drugs, which can cause someone to be more immobile. Steroids can impede healing, says Dotson. Don't overlook a previous pressure ulcer: That's "one of the most important things" to look at in your risk assessment, according to Ayello.

"Double check all of the assessment parameters and correlate them to the person's Braden or Norton and skin condition," advises Dotson.

Also document that you have considered specific risk factors. For example, you might write: "The resident's skin looks clear now but his mood is poor and he's taking steroids, etc.," suggests Dotson.

4. Develop a schedule for evaluating residents who fall into the "suspect pool" for developing a pressure ulcer, advises Dotson. A person may fall in the risk group based on his Braden or Norton Scale scores or if he triggers the Pressure Ulcer RAP--or if he had a long surgery or immobility from other causes, she says.

Document your skin assessments and the various preventive interventions, which "shows you are being proactive," Dotson suggests. "Then if a resident does have skin breakdown, surveyors aren't as likely to cite the facility."

Assessment tip: Use standardized risk assessments such as the Braden Scale at admission and weekly for the first four weeks, suggests Barbara Braden, PhD, RN, FAAN, in Omaha, NE, who co-developed the Braden Scale. After that, pair the assessment with another assessment parameter, such as the resident's weights, she suggests. "Facilities tend to weigh residents at designated intervals or at least monthly," she notes.

Editor's note: View the CMS Webcast, "Pressure Ulcer Care, Volume 1," at cms.internetstreaming.com. For more information on how to augment the Braden and Norton Scales, including advice from Barbara Braden, see "The Right Risk Score Doesn't Mean You're Home Free In Preventing Pressure Ulcers," in the March 2006 MDS Alert. For subscribing information, call 1-800-874-9180.