Completed Self-Assessment Worksheet Facility Name: Sunny Tree NH Date Completed: 07/01/16 Completed By: Change Team Section 1: Pressure Ulcer Tracking and What tools, if any, does your facility use to monitor pressure ulcer healing? Check all that apply. Individual Patient/Resident Level Facility Level Advancing Excellence Pressure Ulcer Tracking Tool Facility-developed forms/database √ √ Corporate-directed forms/database Paper records/log √ √ PUSH – Pressure Ulcer Scale for Healing Tool BWAT – Bates-Jenson Wound Assessment Tool None of the above Other (specify) How often does your facility reassess pressure ulcers? Daily At every dressing change √ Weekly √ Other (specify):___we identify new pressure ulcer daily and at admission_____________ Does your facility collect the following information? Facility at Large Unit Level a. Total count of ulcers √Yes No Yes No b. Count of ulcers by stage √Yes No Yes No How often is the information updated? Total count of pressure ulcers is updated:
QAPI or quality improvement review QA Coordinator Administrator – A Nurse Managers – A Nursing Supervisor – A Dietitian – A DON – A Rehab Director – A Nursing Assistants (one from each unit) – A Infection Control Nurse – A Social Services Director – A Activities Director – A Medical Director – A Monthly Yes Skin or Wound review meeting Program Champion (Wound Nurse) Dietitian – A Nurse Managers – A Nursing Assistants – A Weekly Yes, any residents with a pressure ulcer is seen on rounds MD/APRN rounds Nurse Managers Physicians - A Weekly No, unless a resident has a pressure ulcer Report or brief with Dietary Department Nurse Managers Dietitian – A Nursing Assistants – A Weekly No, unless a resident has a pressure ulcer. Report or brief with Social Services Department Nurse Managers Activities Director – A Social Services Director – A Nursing Assistant - V Weekly No, unless a resident has a pressure ulcer. Report or brief with Therapy Department Nurse Managers Rehab – A Nursing Assistants – A Weekly No, unless a resident has a pressure ulcer. Report or brief with “Other” N/A N/A N/A N/A Other N/A N/A N/A N/A Abbreviations Used: CNA = Certified Nursing Assistant; MD/APRN = Medical Doctor/Advanced Practice Registered Nurse; QAPI = Quality Assurance and Performance Improvement.
Meeting Descriptions and Suggested Pressure Ulcer Healing Reports - For Use With Implementation Scripted Exercise Nursing Home Meetings Meeting Description Typical Attendees and Leads Existing Pressure Ulcer Report Pressure Ulcers At Risk for Delayed Healing Weekly Wound Rounds Report Weekly Pressure Ulcer Treatment Summary Report Pressure Ulcer Counts by Month Care plan meetings Weekly review of resident care plans. Reports help care plan change decisions. Multidisciplinary team. DON or ADON typically leads the meeting. X X Nursing assistant shift change Report CNAs meet at shift change to share summary of residents’ clinical status and residents’ care plan interventions for CNA followup. The charge nurse typically generates the On-Time reports for the new CNA staff at the beginning of the shift to identify residents with changes in risk. Usually done weekly. Charge nurse/nurse manager and CNAs. Charge nurse or nurse manager typically leads the meeting. X Dietary Department internal review This is a weekly meeting within the Dietary Department. Report supports nutrition plan review and changes. Dietary Department staff Director of the Dietary Department typically leads the meeting. X MDS assessment documentation Reports may be used to support MDS nurse review of resident records and aids MDS assessment documentation. MDS nurse and other disciplines responsible for MDS assessment documentation, including Dietary and Rehab. X X X X Nurse shift change report Nurses meet at change of shift to review resident clinical and risk status. On-Time Risk reports help identify residents at risk for pressure ulcer development that need attention. Nurse managers or charge nurses. Nurse managers or charge nurses typically lead the meeting. X X Quality improvement review Department heads
Weekly risk meetings (e.g., pressure ulcer healing risk or nutrition risk) Multidisciplinary team review of residents at risk. The purpose of using the reports is to identify persons with risks associated with pressure ulcers, review care plans, and help update interventions. DON or ADON, nurse manager, wound nurse, dietitian, and Rehab director or Rehab therapist depending on focus of meeting. DON or ADON leads the meeting. X X Weekly wound review meetings* Multidisciplinary team weekly review of residents with pressure ulcers or skin integrity issues. Reports provide information about current and changing risks for pressure ulcer healing and can aid root cause analyses and decisions about ulcer treatments and interventions. DON or ADON, nurse manager, wound nurse, physician, NP, and QI director. The team conducting wound rounds typically attends this meeting for a more detailed review of the resident chart and current care plan interventions. Physician, dietitian, therapist, and QI staff, who may not attend wound rounds, attend this meeting. DON typically leads the meeting. X X X X Wound rounds Multidisciplinary team weekly review of residents with pressure ulcers. The team rounds on residents with a pressure ulcer and uses pressure ulcer healing reports to support decisionmaking on pressure ulcer treatments and interventions. Nurse manager, wound nurse, wound physician, NP, and CNA Physician, wound nurse, or DON typically leads the meeting. X X Abbreviations Used: ADON = Assistant Director of Nursing; CNA = Certified Nursing Assistant; DON = Director of Nursing; MDS = Minimum Data Set; NP = Nurse Practitioner; QI = Quality Improvement.