Articles Posted in Pressure Ulcers

A recent study, published in the Journal of Clinical Nursing, looks at how the level of education about pressure sore prevention among nursing home staff affects the level of care provided to residents. The article, titled “Pressure ulcers: knowledge and attitude of nurses and nursing assistants in Belgian nursing homes”, relates the results of a survey of registered nurses and assistant. The survey team interviewed 145 nursing staff across 9 different nursing homes and observed the care of 615 residents.

The findings of the study show that knowledge about pressure sore prevention is very low, with registered nurses scoring on average 29.3%. The mean score for certified nursing assistants is even lower at 28.7%. RNs and nursing assistants are in charge of taking steps to prevent the development of pressure sores. And yet this study found that the full measures stipulated by nursing home guidelines were only carried out in 6.9% of residents designated as at risk for pressure sores.

Pressure sores, or Decubitus Ulcers, are areas of dead skin tissue, which can be very painful and lead to infection and the breakdown of skin and muscle. These sores arise from extended periods of unrelieved pressure on a person’s skin. They are commonly found on the joints, back, and head, where the skin contacts or rubs against a bed or chair. Pressure sores are classified in four stages of severity, with stage IV resulting in extreme skin breakdown to the extent that the bone may be exposed. Pressure sores of any stage are very painful and can lead to a lower quality of life.

The development of pressure ulcers is preventable. By moving and changing position periodically, pressure on the skin can be relieved and pressure sores prevented. Other factors such as a healthy diet and good hygiene also help. Nursing staff play a vital role in this process. They are responsible for turning and repositioning at risk residents as well as assisting in activities that help build muscle and maintain skin health. These nurses and nursing assistants should be informed of pressure ulcer prevention measures as well as the proper care procedures if for any reason a resident does develop an ulcer.

One of the main reasons that residents in nursing homes develop pressure sores is understaffing. Many nursing facilities do not have adequate numbers of staff to perform the duties necessary to prevent pressure ulcers in all of the residents. This does not excuse the facilities as the Patients Bill of Rights mandates that all those residing in care facilities have the right to be free from developing any bed sores. It is the responsibility of the nursing home to hire enough staff to properly care for all of the residents. The RNs and nursing assistants should also be fully educated, in subjects such as pressure sore prevention, so that they can provide the care and attention that each and every person in a nursing home deserves.

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The March 2012 issue of the Journal of Clinical Nursing studies trends in pressure ulcer prevention in skilled nursing facilities in its article titled “Registered Nurses’ Attention to and Perceptions of Pressure Ulcer Prevention in Hospital Settings.” Pressure ulcers continue to be a major problem in nursing homes and yet, many facilities fail to prioritize the prevention of these wounds, although they are one of the greatest sources of unnecessary suffering among the elderly. The study reaffirms this problem and observes that Registered Nurses (RNs) typically undervalued the importance of pressure ulcer prevention techniques.

Before reporting the actual procedures and results of the study, however, the article first discusses important prevention techniques that it would be considering when observing nursing homes and their ability to effectively prevent pressure ulcers. First off, pressure ulcer prevention must be administered from an early stage. The study reports that identifying and treating the problem early on can actually decrease the chances of the development of a pressure ulcer by 50%. Some common and effective prevention methods include repositioning and usage of support surfaces, such as foam or air mattresses. Nutrition was also found to be important. Patients who took nutritional supplements were able to successfully lower their chances of developing pressure ulcers.

The study consisted of two parts. The first portion involved an interview with the RNs. Highlights of these interviews reveal a heavy reliance of RNs upon their assistant nurses. Instead of providing direct care themselves, RNs delegated many duties to assistant nurses, admitting that they did not have time to implement or supervise these activities themselves. This confession presents the widespread issue of understaffing in skilled nursing facilities. Even when staff as a whole is sufficient in numbers, nursing homes are often lacking in their employment of RNs. Previous studies have confirmed that direct care from RNs specifically is especially important in the prevention of pressure ulcers, as well as many other health complications that are encountered in nursing homes. With regard to quality of staffing, the truth of the matter is that assistant nurses are much more prevalent and highly staffed than RNs in skilled nursing facilities. This reality makes it especially important for you to ensure that these nurses are well-educated and trained to provide your loved one with the care that he or she needs.

In addition to being knowledgeable of pressure ulcers, and other health-related issues that the elderly may encounter, nurses must also possess basic administrative, organizational, and communication skills in order to allow for the smooth operation of a skilled nursing facility. Many nurses who participated in the study admitted that they felt that the documentation of procedures and treatments was an unnecessary, cumbersome step in the caretaking process. RNs trusted that their assistant nurses were implementing prevention techniques, even if there was no documentation of them. However, careful and accurate documentation of medications, treatments, and health problems is absolutely necessary in optimizing the quality of care that a patient receives. By keeping a patient’s medical files organized, physicians and other third parties can more easily assess the condition of the patient, and thus prescribe the most effective treatments.

Proper documentation also contributes to the formation of an effective care plan. Nurses who participated in the study, however, claimed that no specific care plans were necessary in caring for patients suffering from or at high risk for pressure ulcers. RNs said that pressure relief was done automatically and that no specific policy was necessary because the nursing staff already knew what to do. If a patient showed signs of a pressure ulcer, then assistant nurses were simply to reposition the patient often and report the pressure ulcer to RNs. Such a mentality truly undermines the individual needs of each patient. No two patients are exactly alike. Therefore, it is absolutely necessary that each patient has a care plan that has been specifically tailored to suit his or her needs.
From its observations, the study concluded that prevention techniques were typically undervalued on an RN’s list of priorities. It also concludes that assistant nurses were unable to recognize risk factors or diagnose the stages of a pressure ulcer as accurately as RNs. This fact further attests to the importance of direct care from RNs. If your loved one’s nursing home is not providing your loved one with proper preventative measures for pressure ulcers, as a result of staffing issues, he or she may be a victim of nursing home neglect.

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A recent article titled “Observing How RNs Use Clinical Time in a Nursing Home: A Pilot Study” observes how RNs allocate their time between direct and indirect care of their patients. While direct care generally involves physical and psychological care and the administration of treatments, indirect care is more administrative, including documentation and reading of medical records and care supervision and management of nursing aides and certified nursing assistants.

The results of the study showed that RNs spent 59% of their time in indirect care, and only 31% in direct care. The remaining 10% was classified as unproductive time, including breaks and mealtimes. Of the time spent in direct care, the majority, 94.6%, was spent in executing general care procedures. The remaining 5.4% was spent in clinical care, which involves the direct care of pressure ulcers, pain management, and nutrition and weight loss. Because direct care from RNs is so valuable, the study encouraged RNs in skilled nursing facilities to allocate their time between direct and indirect care more wisely.

Despite common misconceptions that direct care is more beneficial than indirect care, previous studies have actually shown that both types of care are important. One study has proven that poor supervision, which is a type of indirect care, is actually related to an increase in cases of pressure ulcers, as well as job dissatisfaction and turnover. On the other hand, direct care is also associated with reduced pressure ulcers, as well as a decline in other adverse outcomes including urinary tract infections, catheterization, and weight loss, while improving the use of nutritional supplements and the maintenance of activities of daily living.

While the implementation of direct versus indirect care each has its own results, under both types of care, the development of pressure ulcers is affected. This is due to the fact that prevention of pressure ulcers is highly dependent on RN staffing levels and quality of care. In fact, pressure sore prevention is so reliant upon the nursing staff, especially RNs, that the prevalence of cases of pressure sores is actually considered to be an indicator of quality of care that a nursing home provides.

Not only does there have to be an adequate amount of staff, however, but this staff must also be well-trained on how to prevent, diagnose, and treat pressure ulcers. While prevention is a completely feasible and necessary part of patient care plans, when pressure sores do begin to form, it is key for nurses to be able to recognize these wounds in their early <a href="stages of development before they progress into more serious stages that can often result in death.

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Recently, as reported by The Baltimore Sun on January 12, 2012, certain health care groups have been engaging in a practice called “upcoding.” This increasingly prevalent practice involves healthcare providers reporting more serious medical conditions to the government, in order to receive higher reimbursement rates. In this specific case, an orthopedic company was accused of manipulating patients’ files to make it seem as though patients had a serious form of malnutrition, called kwashiorkor. The company denies these claims and is fighting back.

However, malnutrition is a serious problem that must not be underestimated. The most obvious sign of malnutrition is weight loss. Malnutrition has many health implications, including pressure ulcers, infections, pneumonia, and falls.

Usually, malnutrition is a direct result of understaffing. When there are not enough nurses working during mealtimes, residents do not receive the proper food and nutrition that they need. Furthermore, mealtime should be a time for positive social engagement, which must be initiated and encouraged by nurses. Often, nursing homes appear to be fully staffed during day shifts, but during night shifts and mealtimes they are actually inadequately staffed. When choosing a skilled nursing facility for your loved one, make sure to visit during mealtimes so that you can get a first-hand experience of what your loved one’s mealtimes will be like. If possible, try a sample of the food your loved one will be eating, and check if a dietician is present. You should also make sure that your loved one is not suffering from dehydration, which often accompanies malnutrition.

Interestingly enough, while some healthcare facilities are “upcoding,” others are “downcoding.” Although “downcoding” entails that the facility receives less funding from the government, nursing homes use this practice to lower their liability. For example, pressure ulcers are relatively easy to downcode because there are different levels of severity. Instead of accurately diagnosing a pressure sore as stage four, which is very serious, nursing homes often claim ignorance and diagnose these sores as being in their early stages of development. They allow patients to continue suffering until the problem is so serious that they must be sent to the hospital. At this point, nurses often claim that previously, the sore was not a severe one, and that it just recently developed into a stage four pressure ulcer. This allows them to attempt pass the responsibility on to the hospital or new care facility to which the patient is transferred. Once again, the development of pressure ulcers, as well as any other health ailments in nursing homes, is usually a direct consequence of understaffing. Regardless, nurses are fully responsible for the prevention of pressure ulcers, and must also be knowledgeable enough to accurately diagnose them, when necessary.

While the list of problems experienced in skilled nursing facilities is extensive, the main purpose of this blog is to emphasize how simple it is for healthcare facilities to manipulate their patients’ health records. For this reason, it is imperative that you are extremely cautious in allowing others to care for your loved one. Even if the facility makes claims and promises to you, it is important for you to ensure that the caretakers are following through with these promises. If you notice that something is wrong, or if your loved one is diagnosed with an illness, we advise you to get a second opinion. All too often, the elderly are taken advantage of and forced to suffer because skilled nursing facilities misdiagnose their patients. Do not allow this to happen to you or your loved one.

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In the January issue of the Journal of American Medical Directors Association, an article titled “When is a Chronic Wound Infected?” studies various methods of determining when a chronic wound is infected and judges which of these methods is most accurate. The article begins by explaining that the skin is a major barrier against infection, and therefore, the risk of a wound becoming infected is extremely high when skin starts to break down. The criteria for a wound to be considered infected requires that bacteria be present in the wound, and that this bacteria is producing tissue damage. There are many different types of wounds, but this particular article studies chronic wounds, such as pressures sores.

Physicians and wound care specialists use colony forming units (CFU) per gram of tissue to measure the presence of bacteria in a wound. They have established the “10^5 Rule,” which asserts that in the surgical closure of ulcers, spontaneous healing will occur at bacteria levels lower than 10^5 CFU. This rule implies that once spontaneous healing occurs, the possibility of infection is diminished and caretakers can conclude that the chronic wound is not infected. However, according to the American Medical Directors Association, the “10^5 Rule” may be inaccurate because there are factors other than the quantitative measure of bacteria that contribute to the development of infections. One such factor is the virulence of the bacteria. For example, certain infections, such as staphylococcus aureus, pseudomonas aeruginosa, and Bacteroides fragilis are so virulent that even at levels below105 CFU, infection is highly likely and requires treatment.

The article determined that a tissue biopsy is the most accurate method of determining whether or not a patient is suffering from an infected wound. However, most skilled nursing facilities do not perform biopsies. Instead, they obtain a surface swab of the wound and test the sample for the presence of infectious bacteria because this process is less costly and much simpler than a tissue biopsy. Despite its practical benefits, the use of surface swabs to determine if a wound is infected can be misleading. Often, the infection is incorrectly diagnosed and consequently, patients do not receive proper treatment and are unable to make a full recovery.

However, laboratory tests are not completely at fault when an infected wound is incorrectly assessed. In nursing homes that are understaffed, as well as in those that employ unqualified nurses, infected wounds are often overlooked, ignored, or inaccurately diagnosed. In fact, pressure sores are usually preventable and it is therefore the responsibility of the nursing staff to take these preventative measures, so that your loved one may avoid the pain and suffering that is caused by an infected wound. In the case that a pressure sore becomes infected, it is the duty of the nursing staff to ensure proper treatment. In addition to the usage of medications, some treatments include pressure relieving techniques, such the use of special mattresses and the repositioning of the patient, as well as the cleaning and dressing of the wound.

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Pressure sores, also known as decubitus ulcers or bed-sores, are common in elderly adults who are not properly cared for or neglected. They are especially prevalent among those who reside in nursing homes, often as a direct result of neglect by caregivers.

Pressure sores can occur when a patient remains in one position without moving, putting pressure on one area of the body for an extended period of time. There are varying degrees of seriousness, but all levels require an attentive and qualified staff. It is the responsibility of the nursing home to take preventive measures, such as repositioning their patients, in order to decrease the risk of pressure sores developing or getting wore.
Treatments for pressure sores also require a high amount of involvement from qualified and well-trained nurses.

One type of treatment involves multi-layer bandaging of pressure sores, as well as special footwear for patients. This treatment has proven to be highly beneficial to patients with pressure sores, as it improves healing and increases overall quality of life. However, despite its benefits, this practice is not commonly used in skilled nursing facilities.

In a recent study, the Australian Wound Management Association and the New Zealand Wound Care Society sought to discover the reason for such low usage of bandaging practices in nursing homes. They hypothesized that, perhaps, lack of funding was the reason for the low usage of bandage treatments in nursing homes. Two different groups were formed to conduct the study. One group received funding for bandage treatments and the special footwear that it requires, while the other group did not receive any funding. However, in the end, both groups were found to have the same rate of usage of bandage treatments. Because there was no significant difference between the group that received funding and the group that did not, the researchers concluded that usage of bandaging in skilled nursing facilities is not effected by the cost of treatment or lack of funding. Instead, the study discovered that the reason for such low usage of bandaging in nursing homes is directly related to staffing issues.

Although the cost of special footwear is substantial, the most expensive requirement for the treatment of pressure sores is nursing care. Because it is such a high cost, care facilities often opt out and hire less staff in attempts to save money and increase profits. However, adequate staffing is absolutely necessary for the proper treatment and prevention of pressure sores. Nurses must also be qualified and knowledgeable. The study found that often times, bandaging was not used because nurses failed to notice the onset of a pressure sore or poorly assessed its level of severity and therefore were unable to provide immediate treatment to patients. In homes that do use bandaging, the study discovered that nurses were often applying the bandages incorrectly, thus lowering the effectiveness of the treatment.

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Under California Health and Safety Code Section 1276.5, skilled nursing facilities are required to provide at least 3.2 nursing hours per patient, per day. The “nursing hours” include only the hours work performed by direct caregivers, which include not only registered nurses and licensed vocational nurses, but also aides, orderlies or certified nursing assistants.

In long-term care settings, especially nursing homes, a high proportion of these certified but non-licensed aides or nursing assistants–non-licensed care providers (NLCPs)–provide the majority of personal care to residents, including transfer, repositioning, and skin care that are necessary for pressure ulcer (pressure sore or bedsore) prevention.

The problem with nursing homes primarily relying on NLCPs for daily personal care is that NLCPs who have the most contacts with the residents lack the knowledge and skills necessary to prevent or identify pressure ulcers. Studies show that long-term care facilities’ training programs and implementation of pressure ulcer prevention protocols primarily involve licensed nurses an not the NLCPs who actually provide a majority of the care, and moreover, many nursing homes even lack established pressure ulcer prevention strategies, guidelines or protocols.

Against this backdrop, the authors of a recently published article titled “A Pressure Ulcer Prevention Programme Specially designed for Nursing Homes: Does It Work?”, published in the August 2011 volume of the Journal of Clinical Nursing conducted an empirical study on a pressure ulcer prevention program specially designed for nursing homes. This program adopted a more structured pressure ulcer risk assessment method and launched the prevention interventions that involved all types of care staff. Notably, it included a separate training course for NLCPs as opposed to licensed nurses and required more involvement from NLCPs in the pressure ulcer prevention protocol.

Twelve weeks after the training and implementation of the protocol, the result showed a statistically significant improvement: both the pressure ulcer prevalence rate and incidence rate decreased from 9% to 2.5% and from 2.5% to 0.8%, respectively. The study results revealed that after the training course, NLCPs were better equipped with the necessary knowledge and skills to prevent pressure sores and were motivated to minimize the risk factors. NLCPs understood that their everyday tasks, such as lifting and transferring residents, were relevant to pressure ulcers and thus they tried to minimize friction and shear force on residents. They were also able to identify and report stage one pressure ulcers–skin redness–to licensed nurses. The Licensed nurses were then able to conduct structured supervision and monitoring of NLCPs, thereby decreasing the risk of developing a pressure ulcer to a higher stage.

The study concludes that a feasible and acceptable pressure ulcer prevention program for nursing homes can be developed, and such a program can motivate NLCPs to improve their performance of pressure ulcer prevention care and increase communication and cooperation amongst all care staff to effectively prevent and treat pressure ulcers. The increased NLCPs’ awareness levels and compliance to pressure ulcer prevention protocols were the main factors that reduced the prevalence and incidence rates of pressure ulcers in the nursing homes studied.

Early detection of stage one pressure ulcers and their appropriate management amongst different types of care staff are crucial for the well-being of nursing home residents. More developed pressure ulcers not only cause more pain but also slow recovery from a morbid condition and require prolonged hospital care. If you have a loved one in a California nursing home, stay involved with the nursing staff and demand that they immediately notify you of any changes in condition. Speak with the nursing staff and make sure not only that they are appropriately trained in pressure sore prevention and detection, but also that they are putting their protocols into practice.

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Pressure ulcers are debilitating chronic wounds that cause torture and suffering to those inflicted, and in severe cases carry the substantial probability of death. Elderly residents of Alameda County and Bay Area nursing homes with physical and or cognitive impairments- especially those with a higher number of medical problems- face the greatest risk of development of pressure sores if they are denied the necessary and appropriate preventative measures. But regardless of any co-morbidities or underlying medical problems, pressure ulcers are by and large preventable.

Because pressure ulcers are preventable, their development is used as a quality indicator for long-term care facilities (nursing homes or “Skilled Nursing Facilities”), hospitals, and effectiveness of physician care. A recent study published in the May 2011 issue of the Clinics in Geriatric Medicine suggests that to effectively prevent pressure ulcers, nursing homes must frequently assess the health condition of a patient. This includes nutrition, mobility, risk for friction and shear, activity level, incontinence, and skin condition. After assessing each patient, an individualized care plan should be developed and implemented for each and every patient in order to effectively prevent pressure ulcers.

The article, titled “Pressure Ulcers in Long-Term Care,” suggests that these strategies for prevention go hand-in-hand with those for treatment of already existing ulcers. For example, it has been shown that frequent repositioning of patients who are bed or wheelchair bound and teaching patients who are prone to inactivity to shift weight and self-reposition are helpful. Other preventive measures include keeping the skin clean and dry, preventing excessive moisture resulting from incontinence, and use of nutritional supplements to maintain good nutrition. For residents who are especially at high risk of developing pressure ulcers, pressure-relieving/reducing cushions or mattresses should be used based on individual needs, comfort, and the cost of the device.

The article emphasizes that the optimal management of pressure ulcers requires understanding of differential diagnosis of chronic wounds and the use of standardized assessment metrics to both recognize and treat pressure ulcers with a systematic approach. It also emphasizes that nursing homes must take precautionary steps toward providing care for conditions that increase a patient’s risk of developing pressure ulcers, including incontinence and malnutrition. The authors conclude that “nothing can replace good personal attendant care with frequent turning, lifting, and transfers that minimize friction and shear.” Therefore, the study once again confirms that adequate staffing of skilled nursing facilities is crucial to carrying out individualized care plans addressing each resident’s specific medical and functional problems.

It has been shown that adequate staffing levels can help reduce the incidence of pressure ulcers in long-term care facilities. In the National Pressure Ulcer Long-Term Care Study more than 0.25 hours per resident per day of registered nurse time and more than 2 hours per resident per day of nurse’s aide time were associated with a lower risk of developing pressure ulcers. The same study showed that a lower than 25% licensed practice nurse turnover in a given facility was associated with better outcomes.

Pressure ulcers are preventable and thus their development is often used as a quality indicator for nursing homes. Residents and families can choose a nursing home by looking at its published incidence and prevalence rates of pressure ulcers at Nursing Home Compare. Statutory standards of care for long-term care facilities under California Health and Safety Code Sections 1276.5 and 1599.1 also make it easier to prove that a nursing home is responsible for allowing a pressure sore to develop.

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