Top Reasons Why Most Nursing Homes Develop Inhouse Acquired Pressure Ulcers and Why We Should Feel ashamed when it happens

[MARK SLAUGHTER B.S.,M.S.,L.N.F.A]

Do you know what one of the most often used arguments in lawsuits against nursing homes is? “The facility allowed the patient to develop avoidable bedsores…” As Nursing Home Professionals, it is our job to ensure that our residents do not develop any bedsores / pressure areas in our facility. But, it happens in every nursing out there at one point or another.
I can’t tell you how many facilities I’ve entered that did not know the first thing about preventive skin care. A recent facility I was at had a full 2 pages of wounds on their wound report. Most of these wounds were in-house acquired…which means they were setting themselves up for an Actual Harm tag on their State survey. I asked a few questions about the skincare program and realized instantly it was broken. Not only was it broken, it was terrible, decimated, a complete failure, practically nonexistant. Since their problems were so prevalent, I decided to use them as a case example to hopefully provide insight to you guys and put some reminders out about what is “good care” these days. This is what I found:
1. They were purchasing skincare products – lotions, body wash, soaps, shampoos, etc. – at the local dollar store because some past administrator thought that was a good way to save money. What a joke! Geriatric skin is not like our skin. Many people believe that you take care of a NH resident’s skin the same way you do a baby’s. Wrong! A baby’s skin is constantly regenerating new cells. A geriatric – well, not so much. It’s more on the degeneration path. These locally bought dollar store products are not pH balanced and usually the first ingredient is some type of alcohol. That’s a great combo to completely dry out your residents’ skin and make it more prone to skin tears and skin breakdown. Make sure you’re purchasing products designed for healthcare application and pH balanced for your NH residents’ skin.
2. Staff were bringing in their own products. Ever wonder what is in the little backpack that many of your CNAs bring with them to work. I did. So, I looked. This employee, out of the goodness in her heart, had brought a full line of her own products – shampoos, lotion, apricot-scented bodywash, aerosol deoderant, etc. that she had purchased locally. The problem is the same as in #1. These products weren’t made for geriatrics. However, it’s not her fault. The facility should have never run out of product and should have ensured the products they were using were of quality.
3. They were not ensuring proper after-bath/after-shower skincare was being provided. Quite honestly, this is the time to really put the lotion on.
4. Peri-wash, when used, was not being rinsed appropriately. It wasn’t the no-rinse type. No brainer here!
5. Sometimes, if the staff didn’t have access to the peri-wash, they used the antibacterial handsoap from the bathroom for pericare. Ugghh!!! Get the right chemicals, keep par levels in stock, and ensure staff on all shifts have access.
6. Residents in wheelchairs did not have pressure relieving cushions. Have you sat in a wheelchair for hours on end? Your butt is gonna hurt! Make sure you have a T-gel, a Keene, or some other type of appropriate pressure relief cushion in place.
7. Residents at risk for skin breakdown were not on pressure reduction mattresses. They were still using the old vinyl spring mattresses. Are these not banned by now? That’s just asking for trouble. Make the effort, get the pressure relief mattresses.
8. Overlays were in use on residents who’d had skin breakdown. Overlays, in my opinion, are pretty much useless. I have seen breakdown occur while residents were on overlays. I have seen facilities attempting to heal wounds with overlays – they didn’t heal. If you have someone on an overlay and they’ve had a stage 4 for 6 months, you have a problem. Get an air mattress – alternating pressure / low-air loss – and get that wound healed! I’m not a fan of overlays, not even those with a pump. I see absolutely no benefit to an overlay. Actually, I believe that overlays take away the benefit of the pressure reduction mattress they’re lying on top of.
9. Nursing was not ensuring the weekly skin reports were being completed. Nursing Home 101 – ensure your weekly skin checks are being done. I’d rather find a Stage 1 pressure area rather than a Stage 4.
10. There was no system for the CNAs to let the Nurses know if they saw a red area when giving the resident a shower. Put a 3-ring binder in the shower room with copies of the little resident diagram so the CNA can circle the area she saw something.
11. Heel boots weren’t on as ordered. Follow the order. Get the heel boots, float heels as necessary.
12. Uncovered foam wedges were in use. Either get it covered or get rid of it/replace it. Uncovered foam will retain moisture, urine, etc. Having that against your resident’s skin is not a good idea.
13. They were double and triple padding. Again, you’re asking for skin breakdown. When you double-pad, you create a wrinkle where the pads overlap. This, in turn, creates a raised area that can create more pressure when a resident is lying on it. I don’t like double-padding. Anything more than 2 is plain laziness.
14. They were putting residents to bed with briefs on at night…on top of a pad. I don’t care what the latest research says, letting the skin air out and keeping check on your residents is always going to be better than leaving them in a brief all night.
15. They were using baby powder. Dries the skin out. Even worse, say the 1st shift uses baby powder on the resident and 2nd shift actually uses the moisture barrier as directed in the facility’s skin care protocol, then you’re gonna have the resident sitting on gunk. No baby powder.
16. Hydration rounds were not being done. Again, Nursing Home 101 – residents need water to ensure good skin turgor.
17. Ineffective use of supplements. House supplements, Med Pass, even Ensure is great, but let’s not forget fortified foods. Your Registered Dietician should be able to make the appropriate recommendations. Depending on the type of wound and what condition it is in, there are nutritional supplements that may benefit you greatly. Arginine is an excellent supplement to assist with wound healing along with zinc, EFAs, Vitamins A, B5, C, E, glutamine, and bromelain.
18. Protein was inadequate. Meals not eaten. This particular facility did not have a strong Restorative dining program to assist residents that needed help to finish their meals. Therefore, their residents were not getting enough nutrition to meet their requirements.
19. TARs incomplete; treatments weren’t getting done. You have to make this a priority. We can not accept the typical excuse from the offgoing nurse that she did not have time to do the treatments. We can’t discover on Monday morning that treatments weren’t done all weekend. That’s unacceptable.
20. They did not have an actual turn schedule for their residents. You know, something like:
6:00 AM Back 6:00 PM Door
8:00 AM Window 8:00 PM Window
10:00 AM Door 10:00 PM Door
12:00 Noon Back 12:00 Midnight Back
2:00 PM Window 2:00 AM Window
4:00 PM Back 4:00 AM Door
Residents have to be turned and repositioned. If not, we’re asking for problems. I’ve seen some residents even develop pressure areas from lying on their catheter tubing for too long.
I promise you that if you use your common sense in tackling your skincare problems, avoid the mistakes listed above, and make it a priority among your staff, you’ll see a dramatic improvement in your skincare and wound report! Good luck!

[Karen Bryan BS, RN, UM, QC, DON]

Mark the worst case for acquired P.U.'s is inadequate nursing evaluation of them coming in the door. Suddenly on day 2 Mr. X has a "serious stage 2" left hip bone with copious drainage. If your facility can arrange instantaneous stage 2 in 48 hours you have just done something only a millionaire could orchestrate!! Market that for if you can do that in 48 hours you can cure it in 24! Then let's not forget sudden increases in P.U.'s which also happens to occur when there has been a "clean out" and agency has been in the building on night shift not to mention a lot of day shift. Suddenly three or four nurses are assessing or NOT, and you have all kinds of P.U's if indeed "they are" and not stasis, maceration, scrape, or something. IF IT DOES NOT BLANCHE it is not a P.U. You have only yourself to blame if your admitting nurse and or at least a RN in the house does not overview the skin assessment on an admission. Do not take credit for the admission who came in with three or four P.U's that one conveniently did not note until the State surveyor came in and was concerned (rightly so) in an increase, and veritable overnight destruction of no known origin. PLEASE...This is the worst of it and what is going on out there day in and day out...

[Cynthia A Weaver]

Comment by Cynthia A Weaver 12 minutes ago
Delete Comment Good blog on preventing pressure sores. The points you make are right on the money. Educating staff is key - if they don't know why they are doing something they are more inclined to "short-cut" around it. Verbal in-services are great if they are listening, but a few don't seem to be able to learn that way. Practical lessons may be the answer for those who can't. Have them physically perform the task and do so repeatedly in differing scenarios while being observed. Then to monitor their progress, spot- check their care. If still resisting the correct way to do whatever task it is, have them re-do the practical step again with a one-on-one to ascertain the root cause of their resistance. The first line in the prevention of pressure sore development is the CNA, so we need to be absolutely sure they know how to do that.

[Karen Bryan BS, RN, UM, QC, DON]

Yes however, the pressure (ahem) is put usually on someone like me a DON or Consultant; recently I was going to take a gig (and trust me another mess in progress and I cannot do but a clean operation and have done enough clean ups to know what is right), and I made rounds 90% of what was reported was not pressure; I had a man with vitaligo (black) who tended to excoriate and what he had was an open wound or laceration; I had two or three on the list that did not blanche; the DADs teaching person and another company they use were just amazed "this DON knows skin" and I said to the Regional "I just wasted 3 hours of my time when State is in your house on a complaint proving I know skin when my resume and what you want from me is proven" and coupled with some other adverse situations this job was not for me. I have burned out somewhat from doing Consultant work; you go in and build a new team; write POC's (yes I do that as well) and save that door from being bolted--six months or a year down the line a friend will alert you to a link of how this or that company was just indicted for Medicaid or Medicare fraud and you just get frustrated. I am not God although very well educated and can put into action with high critical thinking almost any situation blind folded; a job I did recently in a brand new state proved that BUT the key is the team one creates and leaves behind. It is NOT easier to play dirty one can market beds and make money going clean well I am now off topic!