Long-Term Care Survey Alert

Surveyors aren't likely to decide that a resident's new or nonhealing pressure ulcer is "unavoidable" if your facility is making these six mistakes in skin care and pressure ulcer management.

1. Skimping on use of positioning devices and pressure-relieving surfaces. The most glaring and easy omission for surveyors to spot? The absence of prescribed pressure-sore prevention devices in a resident's bed and chair. Surveyors will also be on the lookout for a systemic lack of ample positioning devices, pillows and support surfaces.

These devices are expensive for facilities strapped for cash under fixed price payment systems. Facilities can, however, work with their vendors who will frequently have a wound care nurse available to provide consultation on the best equipment and support surface for each case, says Donna Duss, a nurse consultant and wound care specialist with Joanne Wilson's Gerontological Nursing Ventures in Laurel, MD.

"Facilities can also use the vendor's expertise in seeking reimbursement," adds Sandra Bryant, a wound care consultant with the same firm.

2. Overlooking the role of restorative interventions in a skin management program, especially continence programs and interventions aimed at improving range of motion and bed mobility. "A focus on keeping residents' joints mobile also helps prevent pressure ulcers," Duss notes, " because once residents develops contractures, you are limited on how you can position them."

3. Leaving residents in wheelchairs too long. "When someone is in a wheelchair, staff may view the person as being 'up,'" cautions B.J. Collard, principal of C.T.S. Inc. in Westminster, CO. "Yet a person can get really vicious pressure ulcers from sitting in a wheelchair all day. So wheelchair-bound residents need to be put back to bed to rest for a time on a regular schedule," Collard notes.

4. Using seriously outmoded skin care and wound treatment methods. Many nurses were trained to use proprovidone iodine or hydrogen peroxide to clean pressure ulcer wounds. But the Agency for Healthcare Policy and Research's clinical guidelines say these agents are too "cytotoxic" to normal tissue for use as wound care cleansers.

"Surveyors can tag a facility for not following standard of practice guidelines," cautions Mary Foote, a wound care specialist and principal of Wound Care on Wheels in Napierville, IL. "Currently, the best form of cleansing is saline irrigation using a [needleless] syringe," she suggests. Or facilities can use an isotonic, non-cytotoxic product.

5. Failing to be aggressive enough in addressing nutrition and hydration. You want to keep those cells well-hydrated or "plump" to better resist breakdown. "As soon as the resident has a reduction in meal and fluid intake that lasts as long as two to three days, the interdisciplinary team should aggressively assess the problem and work to correct it," Duss advises.

Residents who have pressure sores require extra nutrients to heal properly, agrees Annette Kobriger of Kobriger Presents in Chilton, WI. "You want to provide a high-calorie, high-protein diet, which is 600 to 800 calories over the usual 2,000 calorie diet, and 40 to 60 grams additional protein."

6. Using transfer techniques that results in shearing forces or skin friction. "Often nursing assistants take pride in being able to turn residents by themselves without realizing that in so doing they are contributing to the risk of skin breakdown," notes Duss. "The nurse leader can monitor and reeducate nursing assistants on this issue."