Documenting Pressure Injuries in Nursing Homes
Is poor documentation hiding nursing home neglect? When it comes to pressure injuries, clear and accurate records can mean the difference between healing and harm. Documentation helps ensure proper treatment and can expose patterns of abuse. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Maranda Kearse to talk about how pressure injuries should be documented and why it’s so important for resident safety and legal accountability.
Kearse:
They have any pain associated with it, there is any change. You wanna update your braining scale, which is their risk for skin breakdown, because that in turn feeds into how you care plan their interventions, and if they need new interventions, you put those in place to keep it from getting any worse.
Intro
Schenk:
Hey, out there. Welcome back to the Nursing Home Abuse podcast. My name is Rob. I’ll be your host for this episode. Today we are talking about how to chart or document pressure injuries. What are we including in that documentation? How often should it be, and why is it important to document it?
We’re not having that conversation alone. We are talking to the amazing Maranda Kearse to walk us through that process. We have the fantastic Maranda Kearse RN, LNC, MSC. Maranda is the owner of Aequitas Consulting LLC, and brings over 20 years of nursing experience and long-term care and acute care. She served in roles including director of nursing, MDS, coordinator and inter ugh infection.
Preventionist. Passionate about patient advocacy. She continues bedside care while providing expertise. Legal Nurse Consulting a Daisy Award recipient. Maranda remains dedicated to improving healthcare outcomes and inspiring the next generation, including four of her seven children pursuing nursing. Maranda, welcome to the show.
Kearse:
Thank you.
Schenk:
First off, seven kids. Okay, seven kids and four of them are nurses. What’s going on?
Kearse:
So I have a blended family. So I have four children of my own and three stepchildren, and actually six of the seven are in healthcare and going into nursing. So none of them are nurses yet, but they’re all working in healthcare and in nursing school.
Schenk:
I imagine that at the dinner table or hanging out watching tv, if somebody like, gets a scratch or bangs their knee against the table or something, you get like a whole bunch of different diagnosis, a whole bunch of different, you know what I’m saying? Like a family of attorneys, yeah. That’s, yes. Super interesting. That just stuck out to me in your bio, out of anything. I was like, oh my gosh. Anyway, so let me ask you this. Okay. The first question would be why in your experience, would it be the case that charting pressure injuries is important?
Why is charting important for pressure injuries?
Like, why would it be important that we document that stuff from, shift to shift or day to day?
Kearse:
Because we have to know how to take care of a person and what they specifically need. It’s not, it’s not the same for every person. You have to make sure that the interventions that you’re putting in place to take care of this person are effective. And if they’re getting pressure wounds, something isn’t working, they need something different. More interventions, different interventions, treatments so that they don’t decline.
A recent study offers important insights on the impact of preventive health measures in elderly populations.
Schenk:
How often are we looking at a resident? Let’s say the resident has developed a pressure injury. Okay. You’re going to bedside and you’re saying, okay, we have a stage two, three, partial full thickness, whatever the case is.
What constitutes a complete assessment of an existing pressure injury?
Schenk:
What are we doing when we are conducting that particular assessment, and how often should we be doing that?
Kearse:
So the wound should be assessed at a minimum every shift, but. It doesn’t mean that the treatment’s being done. So if they have a treatment that’s every other day, you at least wanna put eyes on it to make sure that the dressing is intact, that it’s clean, that there’s nothing that’s pulling the dressing off or getting underneath it in the meantime until the next dressing change.
But the actual wound. Should be assessed every time the dressing changes due. And measurements are a minimum of every seven days.
Review the latest findings on the impact of preventive health measures in elderly populations.
How often should a pressure injury be documented?
Schenk:
Okay, so let’s get super, just like high level when we say assessment of a one. And let’s just say, for example, at stage three, so let’s just say we have a stage three full thickness wound, okay? What do you mean when you say assessment?
Kearse:
So if the dressing change is not due that day, I wanna make sure that it’s clean, dry, and it’s intact. But if I’m assessing the wound, I wanna know what it looks like, what where it’s at, if there’s any drainage, if there’s any odor, the length, width, and depth of it to make sure it’s not deteriorating that what you’re.
What you have in place for a treatment is effective.
This article evaluates care outcomes on the impact of preventive health measures in elderly populations.
What qualities of a pressure injury should be documented?
Schenk:
An assessment essentially is just going through and observing a checklist of things, right? Yes. Okay. So now, again when the, when typically when you are assessing a wound, and again, we’ll keep it as a stage three wound, so it’s okay.
It’s potentially a dangerous thing. And you’ve done the assessment, what are you documenting, if anything? Or is it just, Hey I did an assessment. Everything looks good, right? Walk us through the process of assessment to what gets put on paper or documented on the electronic chart.
Kearse:
I wanna know. Any surrounding skin issues that they have around the wound. I wanna know any drainage, any odor to the wound, any changes in it from the last assessment, if there’s any changes or deterioration. Even if the measurements are not due, say for another four days, I’m gonna measure that and make sure that a new treatment or a new intervention could be put in place.
This research discusses nurse-led wound care interventions on the impact of preventive health measures in elderly populations.
’cause otherwise they’ll deteriorate. Another four days waiting for the measurements to be done. But you also assess pain if they have any pain associated with it. If there is any change, you wanna update your brain and scale, which is their risk for skin breakdown, because that in turn feeds into how you plan their interventions, and if they need new interventions, you put those in place to keep it from getting any worse.
Explore how nurses perceive patient dignity on the impact of preventive health measures in elderly populations.
Schenk:
Maranda, that was a test because I have the watermelon book for the surveyor manual, and you hit every single one. Location, stage, size, presence of drainage or exudate, pain wound bed description. So that’s how, Maranda knows her stuff, is that she’s going, she’s got the surveyor guide memorized in her head.
So tell me this, okay, so you’re saying in your experience that measurements at minimum are once a week.
Kearse:
At a minimum it has to be every seven days. So even if you do it on a Tuesday, one week and a Wednesday, the next, you’re already out of compliance because that’s eight days.
Learn about the most common risk factors for pressure ulcers in nursing home residents.
Schenk:
And what would be the case that you would wanna do it more often?
What is, you mentioned it a second ago, but I wasn’t paying attention because I was thinking about the, about putting the surveyor document in the camera, but what, what would make that be more sooner?
Kearse:
Just if I’m doing the dressing change and I notice that it’s deteriorating then I would go ahead and measure it so that the interventions and the treatments can be changed right then instead of waiting till the next scheduled day for measurements.
This article offers a visual guide to the stages of bedsores with pictures.
Schenk:
And how is that typically done? Is there a special tape measure? Do you just put your thumb down there or.
Kearse:
There’s usually tape measures for wounds.
Schenk:
And typically, is it when you’re doing this, and tell me if, forgive me if we’re too in the weeds on this, but like how do you know from what point to what point, is it the edge of the wound bed or do you include like the redness on the outside?
How are, when you’re talking about length and width, like where does the length and width start and end?
Kearse:
So it’s usually at the very edge of the wound, but then you also describe the outer edges if they’re rolled or if they’re macerated, if there’s redness, anything outside of the wound. That’s the peri wound area. So you would describe that separately. But the actual wound is the length and width.
Understand how long it typically takes for pressure ulcers to heal and what affects the process.
Schenk:
And what about depth? Are you literally just sticking the tape measure into the wound and taking a best guess
Kearse:
Based on what with the depth you can, if the wound is big enough and put it like that. But we usually use a Q-tip and mark the Q-tip and then measure the Q-tip.
Schenk:
That’s way better than what I suggested. ’cause I’m sure that the Q-tip has got less germs on it. Okay. So like using the Q-tip as the mark and you put the Q-tip up next to the tape measure. That makes sense? Yes. Okay.
All right, so then you got length with, and talk about the, if you can. Why different types of liquid or drainage in the wound would matter to your assessment and kind of what they look like? Run us through the different types that you might see.
Kearse:
So some of the drainage, it could be clear drainage, and you want the wound bed to be moist and to have that circulation.
So that’s not a bad thing, but if the drainage starts to become purulent or have a. A pus appearance. Then your concern is for infection.
If a resident dies from severe bedsores, learn whether you may have a valid wrongful death claim against the nursing home.
Schenk:
So every time that you go to that resident and you assess that wound, is it the case that you then, you’re looking for all those things that you described, like the pain, presence of pain, drainage, all that kind of stuff is, and all that. Every time you do that assessment, it gets documented or it should.
Kearse:
It should. But like I said, if the treatments are scheduled for every other day, you’re not gonna pull the dressing off to check it necessarily. But a lot of times we have to do the dressing change extra just because it gets dirtier, it gets pulled off, or it gets wet and, you don’t want a wet dressing unless it’s ordered that way because it breeds bacteria that way.
Get answers to whether you can sue a nursing home for pressure ulcers caused by neglect.
When should a nursing home take photos of a pressure injury?
Schenk:
What about the idea of taking pictures of the wound? Is this something that’s typical? Atypical?
Kearse:
I think that taking pictures of the wound is becoming more common now than it used to be. But I think it also depends on how bad the wound is or how fast it developed when they take pictures.
Schenk:
And I guess I mean it for me, as a lay person, it makes sense to take pictures, right?
But what is it? What’s really happening when you’re taking the pictures? Is it just because theoretically you’ve got linked with depth, presence of drainage, et cetera, et cetera. So like theoretically you have it all there. Like what? What’s the extra help from the photo?
Kearse:
I think that the photos help validate the healing process, so you can actually see.
How it occurred and how it progressed. But it also guides care planning to make sure that what you say this wound is, what kind of wound it is or what stage it is that’s accurate.
Preventing Pressure Ulcers in Nursing Homes – Episode 118 covers best practices to reduce risk.
What is reverse charting?
Schenk:
Have you ever heard of the term reverse charting? And if so, what is it?
Kearse:
Reverse charting is. You wanna chart everything at point of care, you don’t always have that opportunity to do that because you don’t have a computer in the room with you and things like that.
So if I’m assessing a wound, I’m gonna take in all my papers, fill it all out. Write the time down and make sure that I can put it in as soon as I leave the room. But that way my measurements are accurate. I’m not trying to remember what the measurements were, because then it’s a best guess. So you basically write everything down at the time and then put it in.
Schenk:
Okay. Put it in later. Okay. So I guess in my mind what I’ve always thought reverse charting was would be something along the lines of like just check marking looks the same as yesterday. Or, the like no presence of drainage or No I guess essentially copying the previous documentation.
I always thought that’s what reverse charting was. So reverse charting is basically just you took information and data, but didn’t enter it into the chart until later.
In this episode, we explore how pressure ulcer assessments should be conducted in nursing homes.
Kearse:
That’s how I’ve always known it.
Schenk:
I see. Okay.
Kearse:
Is that you still do it point of care, but you do it from paper into the chart because you don’t have the ability to have the computer in there.
Schenk:
I gotcha. Okay. You’re, hey, you’re the I’m just a lay person. What about the idea of what I’m describing, which is to say that we didn’t, I didn’t chart anything on that pressure injury. Because nothing changed from yesterday, would you say that’s not appropriate, even if nothing changed, something still has to be in the chart to document that.
Kearse:
A lot of facilities do chart by exception, so you only chart if something is out of the ordinary. But a wound is out of the ordinary, so there should be some documentation to show that. Somebody put eyes on that wound to make sure that even if it, like I said, the dressing wasn’t due, that the dressing they have on is clean and it’s dry and it’s intact.
There’s no odor coming from it. There’s no drainage coming through. There should be something to say. Somebody looked at that.
Understanding Pressure Ulcer Staging – Episode 135 breaks down wound categories and legal consequences.
What is reverse staging a pressure injury?
Schenk:
I was confusing reverse charting with charting by exception. So that’s my bad. So you get to learn in real time on this show. Okay, that makes sense. So now speaking of reverse stuff, what is reverse staging of a pressure injury?
Kearse:
Reverse staging would be, say you have a stage four, you have got muscle or bone or tendons showing, and then it’s healing. It used to be that they would say now it’s a stage three. They don’t do that anymore. They recommend that you don’t do that because the tissue that fills in a wound is not regular tissue.
It’s scar tissue and things. So whatever the highest stage wound is, you should continue to use that and just refer to it as a healing stage four instead of now, it’s a stage three. Now it’s stage two.
What Prevents Pressure Ulcers from Healing? looks at clinical barriers and care failures.
Schenk:
Because I guess as you indicated, that would give the false impression that it’s as stable as a, a new stage three or a new stage two, when in fact it’s not, because the underlying tissue is still not great.
Kearse:
Yeah. And stage two, the peri wound, is now scar tissue because it’s a healing stage four. It’s not, it’s more likely to break down again. So you have to know that. It’s a healing stage four instead of just a stage two because your tissue around it is not as stable.
Schenk:
Okay. So you mentioned a little earlier that we wanna document the wound edge or the skin surrounding the wound.
What are some of the things that we’re looking for? What, are we looking for redness, like blood? I don’t know. Walk us through that. That checklist.
Kearse:
So the surrounding tissue, we’re looking for redness. But you also want to know if it’s red, if it’s blanchable. Because if you have redness around your wound that’s not blanching, chances are that wound is gonna get bigger because it’s already started Stage one around the wound.
And it can also be indicative of the interventions not being appropriate. Maybe there’s too much pressure on that wound and you need to change your interventions.
Are Pressure Ulcers Avoidable? discusses whether these injuries result from unavoidable circumstances or neglect.
Schenk:
And I guess at the end of the day, like you wanna err on the, with the pressure injury, especially three or four, you want to err on the side of too much documentation rather than too little.
Kearse:
Yes.
Schenk:
Okay. Maranda, we really appreciate you coming on the show today and sharing your knowledge with us.
Kearse:
Thank you for having me,
Schenk:
Folks. I hope you found this episode educational. If you have an idea for a topic that you would like for me to discuss, please let me know. If you have an idea for a guest that you would like for me to talk to, please let me know that as well.
New episodes of the Nursing Home Abuse Podcast. Come out every Monday and remember skillet cook bacon every day. Okay. None, nothing in the oven. Just cook it in the skillet. Makes your house smell better. The whole shebang to win the mug. Good luck to you. For those that enter, of course, no one will.
It’s the reverse thunderdome. Nobody enters. Nobody wins. And I guess with that. We’ll see you next time.
Maranda Kearse’s Contact Information: