20 Reasons Why Most Nursing Homes Develop Inhouse Acquired Pressure Ulcers and Why They Need a Good Kick in the Pants!

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 home 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 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.  That’s part of the Central Supply Coordinator’s job and ultimately the administrator’s to ensure each shift has access to all the supplies they need to do their job and that those supplies are of high 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 or even vaseline 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 worthless.  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 wound 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 and, 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. On the same token, ensure the Bradens or skin risk assessments are completed as well.
  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 where she saw something.  She should then turn this in to the treatment nurse or charge nurse for followup.
  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.  Common use of double-padding and triple-or-more-padding is just a sign of 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 frequent check on your residents is always going to be better than leaving them in a brief all night.  The only people who say briefs are better while in bed are the ones who don’t ensure proper rounds are being made.
  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 utilization 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 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.  Let’s not forget that wound can burn up tons of calories trying to heal.  Your resident will need more than he/she did before the skin breakdown.
  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.  You should enfore the expectation that treatments will get done with an iron fist.
  20. They did not have a 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 Midnt.     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 or have areas on their ears from oxygen tubing.
Bonus!!!  21.   They were not sharing the wound report with the CNAs on a weekly basis.  Every Nurse and CNA on every shift should be aware of who has a wound and what the current state of it is.  They should see how making a few changes that we’ve identified above will jumpstart the healing process.  Your CNAs care about the residents.  Once they see that they can make a difference and help heal those wounds, your wound report will clear up fast!
I promise 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!
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