Overview
Part 1: Data Interpretation
Looking at the data as the supervisor, I would be concerned about the pressure ulcer rate at this nursing home. The facility rate is 15.4%, compared with 10.7% in Georgia and 8% nationally. That is a pretty noticeable difference. The facility is 4.7 percentage points above the state rate and 7.4 points above the national rate. This tells me we need to look at what is happening with pressure injury prevention on the units and whether the same prevention steps are actually being followed from shift to shift.
The state trend also gives some useful background. In 2019, Georgia was around 6.3%, while the national rate was around 4.8%. Georgia was about 5.5% in 2018, so the rate went up the following year, while the national rate stayed close to 4.8%. I would not directly compare those older numbers with the facility's current 15.4% because they are from different time periods. What I can say is that Georgia was already running higher than the national rate in that data set, and our facility is currently higher than both the state and national benchmarks.
Strength and Weakness of the Data
A strength of the data is that I can compare the nursing home with both Georgia and the country. The facility's 15.4% would not mean as much by itself. Seeing it next to 10.7% and 8% makes it much easier to see that there is a problem and that improvement is needed.
A weakness is that the data do not tell me what caused the pressure ulcers. For example, I cannot tell from these percentages if residents were not being turned, if incontinent care was late, if barrier cream was missing, or if skin changes were noticed but not reported. I would need to look at the residents' charts, skin assessments, turning documentation, supplies, and what staff are doing on the floor before I could figure out where the problem is coming from.
Never Event
A Never Event is a serious and usually preventable event that should not happen when proper safety measures are being followed. PSNet lists stage 3, stage 4, and unstageable pressure ulcers that are acquired after admission to a healthcare setting as serious reportable events (UC Davis PSNet Editorial Team, 2024). If that happened in this nursing home, I would see it as a sign that we need to find out where the resident's care broke down. I would look at turning and repositioning, skin checks, incontinent care, nutrition, documentation, and whether changes were communicated to the nurse. It can also have a major effect on the resident because a severe pressure injury can cause pain, infection, more treatment, and possibly hospitalization.
Part 2: In-Service Plan
For the in-service, I would have the RNs, LPNs/LVNs, and UAPs attend together. I would keep it hands-on instead of making it a long lecture. We would go over skin care, barrier cream, turning and repositioning, and what changes need to be reported to the nurse. AHRQ developed its On-Time Pressure Ulcer Prevention program specifically to help nursing homes use resident information to recognize pressure ulcer risk earlier and improve prevention (Agency for Healthcare Research and Quality [AHRQ], n.d.).
Barrier Cream
Barrier cream protects the skin from moisture, especially when a resident is incontinent. After incontinent care, the area should be cleaned gently and dried before the barrier cream is applied according to the product directions and care plan. It is important that barrier cream does not become a substitute for changing a wet or soiled brief. UAPs can apply routine barrier cream if the facility policy and care plan allow it. The nurse still needs to assess any redness, open areas, or other changes and decide if the resident needs additional treatment.
Complications of Immobility and Prevention
Pressure injuries. Residents who stay in the same position for too long have constant pressure on the same areas of skin. Staff should reposition them according to the care plan, keep the skin clean and dry, offload the heels, use ordered pressure-relieving equipment, and report skin changes early.
Deep vein thrombosis (DVT). Not moving much can cause blood to pool in the legs and increase the risk of a clot. Residents should be encouraged to move as much as they safely can. Range-of-motion exercises, getting out of bed when appropriate, fluids when not restricted, and ordered DVT prevention should also be used.
Constipation and fecal impaction. Immobility can slow down the bowels. Staff should monitor bowel movements, encourage activity, fluids and fiber when appropriate, and follow the resident's bowel regimen. Waiting several days to address constipation can make the problem harder to treat.
Contractures and decreased mobility. When residents are not moving enough, their joints can become stiff and their muscles can weaken. Repositioning, proper body alignment, range-of-motion exercises, ADLs, and restorative nursing or therapy can help them keep as much movement as possible.
How I Would Follow Up
At the end of the in-service, I would have staff answer a few questions and demonstrate how they would reposition a resident and apply barrier cream. Then I would do random checks for about four weeks. I would look at whether high-risk residents are being turned as ordered, whether incontinent care is being done on time, whether barrier cream is actually available on the unit, and whether staff are documenting and reporting skin changes.
I would also keep track of new facility-acquired pressure injuries and compare them with where we started. If the number starts coming down and the audits show better follow-through, I would know we are moving in the right direction. If nothing changes, I would look at the reason before doing another general in-service. If the problem is missing supplies, then we need to fix the supply issue. If turns are still being missed, I would follow up with the staff involved and look at staffing, assignments, and documentation. The point would be to fix whatever is actually getting in the way of the care.
References
Agency for Healthcare Research and Quality. (n.d.). AHRQ's safety program for nursing homes: On-Time pressure ulcer prevention. U.S. Department of Health and Human Services. https://www.ahrq.gov/patient-safety/settings/long-...
UC Davis PSNet Editorial Team. (2024, September 15). Never events. PSNet, Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/primer/never-events