Nursing Home Pressure Ulcers: 10 Things You Didn’t Know

Nursing home pressure ulcers continue to be a common killer. Causing infection and disease, these injuries are a painful scourge that needs to be reduced and eliminated. In this week’s episode, we talk about the top ten things that you might not know about pressure ulcers.

Hello out there. Welcome back to the Nursing Home Abuse Podcast. My name is Rob. I’m going to be your host for this episode. We are going to do another top 10-episode in the style of David Letterman. For those out there who used to watch David Letterman back in the day, he would do the top 10 lists. This is our own version of top 10 list – so top 10 things that you didn’t know about pressure ulcers.

Nursing home pressure ulcers should not be back-staged

Number 10, pressure ulcers should not be back-staged. So very quickly what staging is – pressure ulcers occur on a continuum that we’ve determined to be in four stages. So stage one and two, the pressure ulcer has either not broken the skin yet or has broken just the first layer of skin. Stages three and four, which are full-thickness ulcers, the wound has gone below the skin into the tissue and the muscle below. So we go stage one to stage four, one being the least developed to four being the most developed.

So what happens sometimes is that a nursing home will document the pressure ulcer, let’s say we’re at a stage three pressure ulcer, and let’s say that they revise the care plan like they’re supposed to, that they reassess the resident and that they make a new care plan with that stage three pressure ulcer with interventions to heal that pressure ulcer. The care plan has the objective to heal that pressure ulcer based on the interventions.

Now let’s say that those interventions worked and that pressure ulcer begins to heal such that it goes from that full-thickness wound back to a partial thickness wound, so you could either consider it to be at stage one or stage two. So it was stage three, it’s healing and it’s getting covered back up with the skin and it would technically either be stage one or stage two. At this time, it is not appropriate to refer to that ulcer as stage one or stage two. It should always be staged at its highest stage. In other words, you can’t back-stage the pressure ulcer. So once a stage three, always a stage three.

And that’s important because typically once you get an ulcer to a stage three or stage four, the damage is done. The area under that skin is going to be compromised so you’re going to be more susceptible. So in terms of the risk involved, it’s better to say that you have a stage three there forever because essentially it’s not going to take that long to get back to a stage three. So no back-staging of pressure ulcers. If you see in your loved one’s records that it was a stage four and then six months later it’s a stage two, that is actually incorrect from a clinical standpoint and it could lead to problems and it could lead to misconceptions for shifts later on down the road for how to care for that area of the body that was a stage three or a stage four.

Smoking can prevent proper wound healing

Okay. Number nine, smoking can prevent proper wound healing. This was such a news flash to me. I had no idea about this before I started this podcast. Even taking bedsore cases, I learned this on an earlier episode of this podcast that smoking cigarettes in fact will help prevent a wound from healing. And how does that work? The primary problem with pressure ulcers is that the pressure prevent proper blood circulation in that area of the body, so the tissues and the skin don’t get the nutrients or the oxygen that’s required to be healthy. So it’s like a circulatory issue or a blood flow issue. And so smoking helps to deprive the blood of oxygen and it puts other carcinogens and other things you don’t want in the blood. So you’re reducing the oxygen that’s going into the blood. You’re reducing the nutrients going into the part of the body that needs it and you’re putting bad things, carbon monoxide, that type of stuff. So smoking can have a detrimental effect to wound prevention and wound healing, so that’s a very important – that’s number nine.

Nursing home pressure ulcers are either avoidable or unavoidable

Number eight, pressure ulcers are either avoidable or unavoidable. And those words are terms of art. An unavoidable pressure ulcer is one that occurs on a person even though the nursing home has properly conducted a comprehensive assessment and assessed that resident for his or her risk of developing pressure ulcers. The nursing home, second, has put in place a care plan to address that resident’s risk of pressure ulcers and has reviewed or revised that care plan where appropriate. Where the nursing home does all three of those things, assessment, care plan, revise the care plan, and the pressure ulcer still develops, then we call that an unavoidable pressure ulcer. It’s not relevant what chronic illnesses the resident has, the age of the resident, the mobility of the resident, the cognitive impairment of the resident. The only thing that matters in determining that pressure ulcer is avoidable or unavoidable is that the nursing home does all three of those things. All of a resident’s characteristics and risk factors should be placed into that assessment, into that care plan and be considered when revising and reviewing that care plan.

So in other words, just because a person has diabetes doesn’t mean it’s a foregone conclusion that they’re going to have unavoidable pressure ulcers. The question is what did the nursing home do about the diabetes as a risk factor for that specific resident? Avoidable, unavoidable – only. It’s kind of like Yoda – do or do not, there is no try. Avoidable or unavoidable, there is no other category.

Nursing home pressure ulcers can come from friction and medical instruments

Number seven, pressure ulcers can come from friction and medical instruments. So on this program, we dedicate about 90 percent of our time when talking about pressure ulcers to the most common pressure ulcers, that being those caused by prolonged pressure on certain parts of the body, so the buttocks and the heels and the shoulder blades. But pressure ulcers can actually come from when a resident is transferring, so moving the body, shifting the body around when going from the bed to a wheelchair or going from the bed onto a lift. Any instance in which skin, particularly moist skin, which can be more frail, is shear, the impact of the movement in the bone inside the body moving underneath the skin on that surface as they’re moving, that friction can be the basis for a pressure ulcer injury.

Also when I say medical instruments, things like trach tubes or casts, like when you break your arm, you get a cast, these types of things prolong pressure on that part of the body or friction on the skin can also cause pressure ulcers, so these are kind of subcategories of their own on pressure injuries – those caused from friction or shear and those caused by medical instruments. Not quite as common, at least in my experience, not quite as common but they do in fact happen in the nursing home. The nursing home must account for these things in the assessment and in the care plans.

Refusal by resident to be turned is not an excuse to give up

Number six, refusal or noncompliance on the part of the resident is not an excuse for bedsore development. So oftentimes in our cases we see that a nursing home is blaming the pressure ulcer on the resident because the resident has refused to eat their protein supplement or didn’t want to be turned or repositioned at a two-hour interval, non-compliance by the resident as an excuse. Non-compliance by a resident, a resident’s choice to decline care is not an excuse for neglect. This is an instance in which the nursing home is going to be required to revise the care plan, and part of that means finding out why the resident has declined the care. Is it because when turning or repositioning the resident, it hurts? Is it a privacy issue, a dignity issue? If so, what are the alternatives? These are the types of things that need to be addressed by the nursing home before non-compliance can be used as a sword against that resident.

What alternatives, what did the nursing home do to reassess, reevaluate, update that care plan to try to work around the noncompliance of the resident. Because again, sometimes it’s not a choice. Pain isn’t a choice. If it hurts, that’s why the resident might be refusing it. Sometimes the resident is acting out for reasons other than what seems obvious, so maybe it’s a side effect of medication. So in other words, just because the resident refused to be turned, just because the resident refused whatever the case may be doesn’t mean it’s a foregone conclusion that they should get a bedsore.

Nutrition and hydration are critical to healing

Number five, nutrition and hydration are critical to wound healing. Number five, nutrition and hydration are critical to wound healing. We had a whole episode dedicated to the healing of pressure ulcers. We had guest Martha Kelso on Episode 138. That’s a great episode if you want to learn more about that. But in that episode, she explained that it’s important to get the proper amount of nutrients, because remember that pressure ulcers essentially come down to a circulatory problem. And the point of the blood, the point of the circulation is to feed oxygen and nutrients to the body. When it doesn’t get it, it breaks down. So understanding that, you want to at least be able to ingest the nutrients that you’re going to need to heal that wound to get that blood to take it to that wound area and heal it, and that includes protein. Protein is essential and vital for wound healing. It helps build muscle. It helps build tissue.

So whenever you have a loved one that has a pressure ulcer, in that care plan, there hopefully should be an intervention that says this individual should increase their amount of protein that can either be done through shakes, like vitamin supplements or through the meal plan itself, like the food that they’re intaking should compensate for protein and calories. Obviously calories should be increased or it should be looked out for. You don’t want to have a decrease in calories because calories, again, you want to have an appropriate amount of calories in order to build up the muscle again. So nutrition, hydration, these things are super critical to wound healing.

Nursing home pressure ulcers should be documented properly by staff

Standard of care requires that nursing homes document wound integrity issues on every resident. So if the nursing home observes a reddened area, a non-blood swollen area, that needs to be documented. And then subsequent documentation needs to build on that. So if there’s a stage three pressure ulcer, in order to really care and provide treatment, you have to understand it. And from shift to shift, you need to have documentation showing the progression or the healing of that wound. So in order to do that properly, you need to have a description of the size, the length, the width, the depth of the wound. What does the skin around the edges of the wound look like? Does it have an odor? Are there complaints of pain? So documenting where the wound is at is vital because that provides the basis for understanding it three shifts from now, three days from now, three weeks from now. Is it getting better or getting worse? We only know that if we have proper documentation, proper descriptions. So nursing home staff should be trained on the appropriate way to document and observe those wounds.

Multiple pressures mean the care plan should be revised

So number – where are we at, number three? Multiple pressure ulcers mean the care plan should be revised. So we have mentioned before that care really comes down to assessment, care plan and revision of care plan. So whenever a resident has developed a pressure ulcer, that should automatically be an indication that the care plan should be revised. So assessment, care plan, revision. So new interventions created to treat that pressure ulcer. So if the nursing home has developed new interventions or have effectuated those interventions but still another pressure ulcer develops, then that’s going to call for another revision of the care plan because something is falling through the cracks here. Something they’re doing is potentially not right. So whenever there is a development of a new pressure ulcer, the nursing home should go back and revise that care plan, try to figure out what’s going on. So if you have it on the left side or on your buttocks, you’ve got one of your left side, is there something that they can do with wedges? Is there something that they can do with more frequent turning or reposition schedule, these types of things? Interventions for the purpose of healing that new wound? So revising that care plan.

High-risk residents should be evaluated at least weekly

Number two, high-risk residents should be evaluated weekly. What that means is that after a comprehensive assessment, if that resident is at a high risk for developing pressure ulcers, then that resident on a weekly basis at minimum needs to do a head-to-toe skin assessment of that resident because obviously if they’re at a high risk, then you want to be looking out for it.

So what this means is the resident, by a nurse or a wound care nurse, is given a head-to-toe assessment of their skin integrity. So what’s documented would be moisture – is the resident sweating profusely? Is the resident incontinent? Are the incontinent episodes frequent? Are they infrequent? Things that would place them at risk of skin integrity on top of just a head-to-toe observation of any type of skin impairments, so are there reddened areas? Are there areas where there are scratches, these types of things? So these need to be done on at least a weekly basis for those residents who are at a high risk for developing pressure ulcers.

And again, comprehensive assessments should occur at regular intervals and the skin assessments are just a part of that comprehensive assessment. But once that assessment spits out that the resident is at a high risk for skin integrity issues, then at least that skin assessment needs to occur now every week.

Assessments should take into account chronic illnesses

Number one, assessments should take into account chronic illnesses. So again, the name of the game is avoidable and unavoidable. Just because the resident has a history of diabetes or a circulatory issue or anemia or whatever the case may be does not mean that that’s an excuse for that resident to develop a pressure ulcer. The assessment needs to take into account those chronic illnesses and chronic issues, and the care plan should have interventions in place that account for those and work around them. So if the individual has diabetes, then an intervention to prevent pressure ulcers might be to make sure it stays in check, the insulin levels are checked so that way it’s controlled. And then maybe the interventions might be, “Okay, we’re going to have specific interventions to check her feet or their buttocks at regular intervals,” like I said, like the weekly assessment.

So there are ways around chronic illnesses. There are a lot of people that are old and have chronic illnesses but not everybody has pressure ulcers. So it’s up to the nursing home taking a person-centered approach, a resident-centered approach in that assessment to prevent pressure ulcers for that specific resident in spite of chronic illnesses and chronic conditions.