Long-Term Care Survey Alert

Here's why you should keep tabs on the prevalence of Stage I and II decubiti.

"Bigger is badder" when dealing with pressure ulcers. And while Stage III and IV ulcers are definitely worse clinically, a high or growing prevalence of early stage pressure ulcers may signal your facility has a bigger problem on its hands than staff might realize--one that could land the facility with G-level F314 tags or worse.

"Seventy-five percent of pressure ulcers that develop in a nursing home are Stage I or II and occur over the sacrum, coccyx or heels, followed by ischial tuberosities," says Barbara Bates-Jensen, PhD, RN, CWOCN, at the ULCA Borun Center for Gerontological Research at the Los Angeles Jewish Home for the Aging.

And a large number of Stage II ulcers is a warning sign because nursing actions--especially those at the nurse aide level--can make a big difference in preventing these early ulcers, adds Bates-Jensen. By contrast, "it's harder to make a case that all Stage III and IV ulcers reflect poor care," Bates-Jensen says. "Those wounds may occur in sicker residents with more comorbidities--or the facility may admit someone with Stage III and IV pressure ulcers." (See "Detect, Address Skin Breakdown That Occurred On The Hospital's Watch," in the next Long-Term Care Survey Alert.)

Watch Out for Friction and Shearing Forces

Many early stage ulcers are caused by friction and shearing, Bates-Jensen notes, which you can mitigate with the right transfer and positioning interventions.

Heads up: Someone with paralysis who requires more assistance to reposition will have a higher risk of skin breakdown due to friction and shear than someone who can move more independently, according to a Centers for Medicare & Medicaid Services' Webcast on pressure ulcers.

And the F314 survey guidance notes that "care plans for residents at risk of friction and shearing during repositioning may require use of a lifting device." In addition, sheepskins, heels and elbow protectors can keep a resident's bony prominences from rubbing together, the guidance states.

Seeing is using: Staff may be less likely to use pillows and common bedding agents to position residents therapeutically than they do waffle heel protectors and other special positioning and cushioning devices, according to a study performed by Kathleen Thimsen, RN, ET, MSN, a consultant in Bella Vista, AR. "The latter may provide a visual cue that the device is something special rather than a piece of bedding," she says.