Organizational Needs Assessment Pressure Ulcer Assessment Checklists This is a series of self-assessment checklists for staff to use to assess processes related to preventing and managing pressure ulcers in an organization, in order to identify areas that need improvement. You will find the checklists useful to look at your current practices critically. Directions  

These checklists are designed for completion by a DON/DNS, QI Nurse or other team leader who knows the organization. The person completing the checklist should consult with appropriate staff in answering certain questions.

Use these checklists as the starting point for a quality improvement project. If you are not sure or answer “no” when answering questions on the checklists, discuss this with your PARRI Regional Director who will assist in moving your quality improvement program forward. Checklists on the following pressure ulcer-related topics are included:      

Screening for Pressure Ulcer Risk Developing a Pressure Ulcer Care Plan Assessment and Reassessment of Pressure Ulcers Monitoring Prevention of Pressure Ulcers Monitoring Treatment of Pressure Ulcers Assessing Staff Education and Training Needs

Screening for Pressure Ulcer Risk Does your organization have a process to screen patients/residents for pressure ulcer risk? (A screening assessment or question that determines if the patient/resident is at risk for pressure ulcers. It does not include a thorough assessment of the pressure ulcer or what needs to be done if the patient/resident is found to have a pressure ulcer upon screening.) ______ NO. If no, this is an area for improvement. Use this checklist to guide your team in implementing a process to screen for pressure ulcer risk. ______Yes. Please continue to the questions below. Does your organization have a process for screening that addresses all the areas listed below?

1. Do you screen all patient/residents for pressure ulcer risk at the following times: Acute care: a. Upon admission b. Daily c. Every shift in critical care areas Skilled nursing facilities: a. On admission and weekly x 4 weeks b. On readmission c. When change in condition d. With each MDS assessment Home care/hospice: a. On admission b. On readmission c. When change in condition d. With each OASIS assessment Personal care: a. On admission b. When change in condition c. If resident is not currently deemed at risk, is there a plan to rescreen at regular intervals? 2. Do You use the Braden pressure ulcer risk assessment tool? 3. Do you adjust the Braden score for: a. Diabetes mellitus b. End stage renal disease c. History of a previous pressure ulcer

Yes

No

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Person Responsible:

Comment:

This material was developed by the QIO program form CMS’ NHQI and is intended as general information. Any individual using the material must consider the possibility of human error, changes in medical sciences, and the need to use clinical judgment in each specific case. These materials were adapted for use by the PA MAP-IT for Healthy Skin project with the permission of the QIO. Page 2 of 9

Developing a Pressure Ulcer Prevention Care Plan Does your organization have a process for developing and implementing a care plan for pressure ulcers for patients/residents who have been found to be at risk or have a pressure ulcer? ______ NO. If no, this is an area for improvement. Use this checklist to guide your team in implementing a process to screen for pressure ulcer risk. ______Yes. Please continue to the questions below. Does the plan of care for pressure ulcers address all the areas below (as they apply)?

1. Does the care plan address individualized interventions and risk factors (as they apply) for: a. Impaired mobility i. Assist with turning, rising, and position ii. Encourage ambulation iii. Limit static sitting to 2 hours at any one time iv. Repositioning in chair every hour and teach people who are independent to shift weight every 15 minutes v. Turning and repositioning plan for patients/residents who are totally dependent b. Pressure reduction i. Support surfaces bed ii. Support surfaces chair iii. Pressure relieving devices iv. Off-loading heels v. Check for “bottoming out” in bed and chair

Yes

No

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Person Responsible:

Comment:

(To determine if a patient/resident has bottomed out, the catregiver should place his or her outstretched hand (palm up) under the surface below the existing pressure ulcer or that part of the body that is at risk for pressure formation. If the caregiver can feel that the support material is less than an inch thick at this site, the patient/resident had “bottomed out”.)

c. Nutritional improvement i. Supplements □ □ This material was developed by the QIO program form CMS’ NHQI and is intended as general information. Any individual using the material must consider the possibility of human error, changes in medical sciences, and the need to use clinical judgment in each specific case. These materials were adapted for use by the PA MAP-IT for Healthy Skin project with the permission of the QIO. Page 3 of 9

ii. Needs assistance with eating iii. Adequate fluid intake iv. Dietician consult as needed v. Medication review d. Urinary incontinence i. Toileting plan ii. Check for urinary incontinence iii. Determine type of incontinence iv. Assist with hygiene v. Incontinence care program e. Fecal incontinence i. Toileting plan ii. Check for fecal incontinence iii. Assist with hygiene iv. Incontinence care program f. Skin condition check i. Open areas ii. Color (red, purple, bluish, etc) iii. Sensation iv. Temperature g. Treatment i. Follows prescribed regimen ii. Appropriateness to wound iii. Treatment reassessment timeframe iv. Goal for treatment h. Pain i. Assess for pain at ulcer site ii. Assess for pain that may contribute to development of pressure ulcers iii. Pain management plan using scheduled analgesics, incident dosing, and/or topical/local anesthetic iv. Medication side effects addressed (constipation, urinary retention, falls, etc.) v. Pain management plan adjusted as indicated – titrate upward or downward

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This material was developed by the QIO program form CMS’ NHQI and is intended as general information. Any individual using the material must consider the possibility of human error, changes in medical sciences, and the need to use clinical judgment in each specific case. These materials were adapted for use by the PA MAP-IT for Healthy Skin project with the permission of the QIO. Page 4 of 9

i. Infection i. Dressings appropriate to contain drainage ii. Keep dressing dry/intact iii. Assess for s/sx infection

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Assessment and Reassessment of Pressure Ulcers Does your organization complete a comprehensive assessment for pressure ulcers for patients/residents who are found to have pressure ulcers upon screening (or, if there is no screening process in place, at any other time)? ______ NO. If no, this is an area for improvement. Use this checklist to guide your team in implementing a process to screen for pressure ulcer risk. ______Yes. Please continue to the questions below. Does your comprehensive pressure ulcer assessment include the following components?

1. Does an appropriate clinician (physician, advance practice nurse, physician assistant, certified wound care specialist) make the determination that a wound is not pressurerelated? If NO, do you have an RN educated in wound care assessment? 2. Do you have a tool available to document pressure ulcer assessment? 3. Does your current assessment/reassessment of pressure ulcers include: a. Location b. Stage c. Size d. Undermining/tunneling/sinus tracts e. Wound bed (tissue, granulation, epithelialization) f. Presence of necrotic tissue g. Drainage/exudate h. Periwound tissue (color, temperature, bogginess, and fluctuation) i. Need for debridement

Yes

No

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Person Responsible:

Comment:

This material was developed by the QIO program form CMS’ NHQI and is intended as general information. Any individual using the material must consider the possibility of human error, changes in medical sciences, and the need to use clinical judgment in each specific case. These materials were adapted for use by the PA MAP-IT for Healthy Skin project with the permission of the QIO. Page 5 of 9

j. Presence of odor 4. Is the patient’s/resident’s pressure ulcer reassessed: Acute care: a. Daily b. With ordered dressing change Skilled nursing facility: a. Weekly b. Daily if worsening or high risk Home care/hospice a. At each visit Personal care a. Per organization policy 5. Are the following related factors considered in your assessment/reassessment: a. Mechanical forces (shearing, friction, pressure) b. Pronounced bony prominences c. Poor nutrition d. Altered cutaneous sensation e. Tissue tolerance f. Effects of medication, chemotherapy, and radiation, if applicable

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Prevention of Pressure Ulcers For patients/residents who have pressure ulcers, does your organization have a process for prevention? ______ NO. If no, this is an area for improvement. Use this checklist to guide your team in implementing a process to screen for pressure ulcer risk. ______Yes. Please continue to the questions below. Does your organization’s process for monitoring prevention of pressure ulcers include these components?

1. Is there a list of possible interventions for the patient/resident at moderate or high risk, that nursing staff may implement to prevent pressure ulcer development?

Yes

No

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Person Responsible:

Comment:

This material was developed by the QIO program form CMS’ NHQI and is intended as general information. Any individual using the material must consider the possibility of human error, changes in medical sciences, and the need to use clinical judgment in each specific case. These materials were adapted for use by the PA MAP-IT for Healthy Skin project with the permission of the QIO. Page 6 of 9

2. Does your organization have a protocol for management of tissue loads? (i.e. positioning, support surfaces, etc.) 3. Are there adequate supplies to provide preventative interventions to all residents who require them? (i.e. adequate pressure redistributing mattresses/chair cushions, heel off-loading devices, pillows) 4. Check the bed support surfaces currently used in your organization: a. Foam b. Static air c. Low air loss overlay d. Low air loss mattress e. Other 5. List the chair support surfaces currently used in your organization: a. air (waffle) b. foam c. gel d. Roho 6. Does your organization use turning and repositioning devices? 7. Do you offload heels? 5. Does your organization have protocols regarding the prevention of pressure ulcers that includes the following: a. Monitoring patients/residents for incontinent episodes b. Incontinent care c. Need for assistance with mobility and bed mobility d. Lift, turn, and position (head of bed