Pressure Ulcer Documentation: Basics and Legal Pitfalls

1. Pressure Ulcer Documentation:Basics and Legal Pitfalls Jeri Lundgren, RN, CWS, CWCN Director of Wound & Continence Services Pathway Health Services

2. Risk of Litigation • Study Published in Health affairs, 22 no. 2 (2003): 219-229 • The Rise Of Nursing Home Litigation: Findings From A National Survey Of Attorneys • Study was done for the year 2001 • 278 attorneys responded from 37 states (60% return of the study) • 8,256 claims handled by these firms • 70% involved wrongful death and 60% involved pressure ulcers, then malnutrition/dehydration, restraint injury & falls • 60% of the claims from the children, next the spouse and then the resident themselves

3. Risk of Litigation • Survey Continued • All named the facility as the defendant • 28% named the Administrator • 1 in 5 named the Physician • 1 in 5 named specific staff • Of the 8,256 claims • 8% went to trail • 88% resulted in compensation • 61% won by the plaintiff • Compensation of $406,000 per claim (nearly 3x the rate of payment of typical medical malpractice • No correlation with quality indicators

4. Risk of Litigation • 2001 Claims worth 1.4 billion • “Nursing home litigation is now widely recognized as one of the fastest-growing areas of health care litigation” • Health Affairs, 22 no.2 (2003): 219-229

5. Risk of Litigation • Pressure Ulcers and litigation • Avoidable – due to poor care or neglect • Public not sympathetic to nursing homes • Families not aware of pressure ulcer or had overall concerns that needs where not met • High return on claims • Lack of education for nurses and physicians

6. Documentation • Implication – If it is not documented it is not done

7. Documentation • Within the first 24 hours of Admission: • Risk Assessment • Skin Inspection • Development of the temporary care plan – based off of the risk assessment • Interventions indicated on the Nursing Assistant assignment sheet

8. Documentation At a MINIMUM interventions on the temporary care plan (within the first 24 hours) should include: Support surfaces (bed and W/C) Turning & repositioning schedules Incontinence care & keeping skin clean and dry Heels elevated off bed Dietary and therapy referrals Topical treatment as ordered (if a wound is present) Monitor for S/S of infection/complications – weekly wound assessment Monitor skin on a daily basis with cares and weekly by licensed staff Update the Physician/NP and family with any skin concerns

9. Documentation • On-going Risk assessment: • Admission • Weekly for the first four weeks after admission • Change of condition (mobility, incontinence, nutritional) • Quarterly/annually with the MDS

10. Documentation • Risk assessment • Break the Braden scale down per risk factor • The Braden is not comprehensive • Ensure EVERY risk factor identified on the Braden/comprehensive risk assessment/MDS is brought forward to the plan of care • Interventions should correlate with risk factors

11. Documentation • Skin Assessment • *Upon Admission • *Daily with cares by the nursing assistants • *Weekly by the Licensed staff • Upon a planned discharge • If the resident has been out for a prolonged period of time • Keep the records!!! * Contained within the F314 guidance

12. Documentation • Nursing Assistant Assignment sheets must contain all Interventions they implement • Recommend to keep the assignments sheets • Recommend having a written form of communication for the aides when they find a skin concern

13. Documentation • Repositioning • Ensure care plan and nursing assistant assignment sheet contain repositioning schedule • Do not recommend documenting every time someone is repositioned – unrealistic and no mandate to do this

14. Documentation • Ensure the following match: • Risk assessment • Skin assessment • MDS/RAPS • Physician orders • Care Plan • Nursing Assistant assignment sheets

15. Documentation • Weekly wound assessment should include: • Location • Date • Type • Stage • Edges • Wound Base • Drainage • Odor • Tunneling/undermining • Pain • Progress

16. Documentation • Nurses notes should reflect the progress of the wound only and wound descriptions should not be duplicated • Pressure Ulcers should show progress in 2 weeks

17. Documentation • Document notification of the Physician/NP AND Family: • Upon discovery of a skin concern • If it is not showing progress in 2 weeks • If the wound declines • Upon healing • Recommend to have the Physician/NP visualize the wound and document you offered this

18. Documentation • Ensure an Interdisciplinary team approach • Notified upon • Discovery of the wound • No Progress in 2 weeks • Decline • Healed

19. Documentation • Monitor treatment records • Treatments are being done • That the order matches the original Physician order

20. Documentation • On-going up-dates of the care plan is imperative • Document location and type of wound on care plan only • Treatment as ordered unless an adjunctive • Ensure the goal is appropriate and realistic • Refer to Nutritional and/or Elimination problem under interventions

21. Documentation • Failure to document resident refusal of care and treatment in care plan • Document the date of discussion in care plan and put resident’s request in care plan • Review quarterly, with re-admission and with change of condition

22. Documentation • Documentation of refusal of cares should include: • Discuss resident’s condition • Treatment options • Expected outcomes • Consequences of refusing treatment (pressure ulcer development, sepsis and even death) • Offer relevant alternatives • Recommend showing residents/families pictures ofpressure ulcers

23. Documentation • Be cautious as to what is written on the 24 hour board • Be cautious what is posted in the facility • Be cautious what is in e-mails • Ensure QA tracking states for QA purposes

24. Documentation • Document communication to outside providers such as dialysis units to ensure continuity of care

25. Resources • Available Resources and Web Sites: • www.wocn.org (Wound, Ostomy & Continence Nurse Society) • Available Guidelines: • Prevention and Management of Pressure Ulcers • Management of Wounds in Patients with Lower-Extremity Arterial Disease • Management of Wounds in Patients with Lower-Extremity Neuropathic Disease • Management of Wounds in Patients with Lower-Extremity Venous Disease

26. Resources • Available Resources and Web Sites: • www.aawm.org (American Academy of Wound Management) Has a list of Certified Wound Care Specialists • www.npuap.org (National Pressure Ulcer Advisory Panel) • www.woundsource.com Great source to find wound care products and companies/vendors

27. Thanks for your participation!!! Jeri Lundgren, RN, CWS, CWCN Pathway Health Services, Inc. Jeri.lundgren@pathwayhealth.com Cell: 612-805-9703