Microclimate and moisture
Activity levels
Tissue tolerance
Total body weight
Repositioning needs
Edema
Shear and friction
Symptom management

Bed entrapment
When considering support surfaces in bed, healthcare providers must consider the risk of entrapment. Health Canada and the FDA have released documents defining the seven zones of entrapment and guidance measurements:

1. Within the bed rail
2. Under the rail
3. Between the rail and the mattress
4. Under the rail at rail ends
5. Between split bed rails
6. Between end of rail and side edge of head or foot board
7. Between head or foot board and mattress end.

Prescription of a therapeutic support surface, whether an overlay or mattress replacement, may impact several of these zones (e.g. zone 2, 3, and 7). A standard measuring device is available to check to see if the new support surface increases the risk of entrapment by allowing spaces greater than those outlined in the guideline. The risk of entrapment may also be greater with support surfaces with large air bladders (these are usually found on low air loss, alternating, or rotating surfaces). These surfaces tend to collapse the further the individual moves to the edge of the surface, even when a perimeter border is present within the mattress.

Entrapment risk: Liability
When an entrapment risk has been identified, bed rails should only be used with extreme caution, and be based on the needs of the individual patient. Some patients find the half bed rail at the head section helpful for repositioning. Another approach for people at high risk is to use an adjustable bed with a very low deck height and a floor mat. This approach allows the bed to be raised during care, to a comfortable height for care providers, but allows the bed to be low enough to help prevent injury if the person falls out of bed. Foam wedges and other devices are also available to help reduce the risk of entrapment.

The standard of care will focus on correct selection of the mattress based on identification of risk, and monitoring the patient.

Dr. Diane Krasner

Get in on the shifting thinking about pressure sores by learning from one of the experts in the field. Dr. Krasner explores these and other controversies in an all new multimedia course that will take place on February 27 and March 5. Set aside the day of February 27 to join us for an interactive course, and complete the course the evening of March 5. Reserve your spot today. Can’t join us on either date? Get the on demand recordings for Pressure Sore Case Analysis and Reports here.

When you register for the course, you will receive 10 articles loaded with essential information about pressure ulcers, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized optional critique of your report. Sign up for Pressure Sore Case Analysis and Reports here.

Fast forward to the 21st century and wound care clinicians are confronted with a totally different situation: hundreds of products, scientific rationale for moist interactive dressings and an emerging evidence-base for product selection.

Pressure ulcer product selection
Current wound care expertise encompasses numerous dressing-related skills including:
• Treating the cause of the wound and addressing patient centered concerns to set the stage for local wound care
• Properly assessing the wound and identifying the dressing requirements
• Selecting dressings based on their form and function for an individual wound’s needs
• Meeting setting-specific requirements for dressing change frequency and maintenance
• Addressing formulary or healthcare system availability as well as reimbursement requirements

Wound care product selection today must be as sophisticated and as evidence-based as possible. Wound dressing product selection process is based on three principles:

• Holistic Perspectives
• Interprofessional Considerations
• Patient-Centered Concerns

Selecting appropriate wound dressing products and supportive care to maximize healing and patient outcomes is a complex process. Dressing and local wound care options based on science and best practices must be filtered by clinical experience and must be consistent with patient preferences, care- giver requirements and setting/access issues. Additionally, effective dressing selection and local wound care planning involve the perspectives of the entire interprofessional team.

Knowing the performance parameters of dressing categories/ individual products and matching these attributes to an individual’s wound can optimize the healing process. But dressings are only one piece of the puzzle. Dressings alone will not promote wound healing, unless the underlying cause(s) for the wound are also addressed (e.g. treatment of the wound cause, blood supply, nutrition, patient centered concerns, local wound care etc.). As the wound changes, the plan of care must change and dressing products may have to be changed.

Appropriate pressure ulcer dressing product selection:

• Optimizes the local wound healing environment
• Reduces local pain and suffering
• Improves activities of daily living and quality of life

Inappropriate presure ulcer dressing selection can:
• Cause the wound status to deteriorate (e.g. wound margin maceration, increased
risk of superficial critical colonization or deep infection, skin stripping).
• Increase local pressure or pain especially at dressing change (dressing removal
and cleansing).
• Increase costs with the need for frequent dressing changes or the selection
of an inappropriate advanced or active dressing.

National and international wound care guidelines and best practice documents mean that there is no longer a local standard of care. No matter where nurses and doctors practice, they will be held to national/international standards of wound care practice. Some experts have argued that the selection of the wrong dressing is just as problematic as the administration of the wrong drug and the clinician would be just as liable in a court of law. If dressings can be shown to delay the healing process (e.g. wet-to-dry gauze dressings in a wound that requires moist wound healing, pain from inappropriate adhesives, failure to treat critical colonization that can lead to deep infection), their use might be deemed negligent by a jury in a court case.

Modified with permission from Dr. Diane Krasner, coauthor of Wound Dressing Product Selection, 2010

Dr. Diane Krasner

When you register for the course, you will receive the full article quoted from here, plus 9 additional articles, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an optional individualized critique of your report. Sign up for Pressure Sore Case Analysis and Reports here.

Current numerical pressure ulcer classification systems (staging, grading, or categories) are problematic and misleading because they imply that pressure ulcers progress through defined stages (from I to IV).

The current numerical pressure ulcer classification systems are intended to describe the anatomic depth of tissue damage. Stage 1 is characterized by non-blanchable erythema of intact skin that may be coupled with alterations in skin temperature and tissue consistency. Stage 2 is a superficial lesion involving the erosion of epidermis with epidermal base or an ulcer with loss of epidermis and a dermal base. Full thickness tissue damage may extend to subcutaneous tissue as in stage 3 pressure ulcers and to deeper supporting structures such as muscle, fascia, joint capsule and bone that are classified as stage 4 pressure ulcers. Evolution of pressure ulcers does not necessarily follow a predictable linear pattern from superficial to deep; from Stage 1 ulcers to Stage 2, then to Stage 3 and finally Stage 4 ulcers.

Deep tissue injury
Accumulating evidence suggests that a number of pressure ulcers (most Stage 3 and 4 ulcers) may initially originate in the deep tissue compartment and progress outward to the dermis and epidermis (inside out theory). Deep tissue injury may not be visible to naked eyes but may take hours to days before any clinical signs are evident. Once observed, deep tissue injury can deteriorate rapidly into deep craters despite stringent and optimal treatment that meets the standard of care. Deep tissue injury has the appearance of a purple or maroon bruise under intact skin that resembles and is often mistaken for a stage 1 pressure ulcer. Donnelly documented that 10% of pressure ulcers were initially diagnosed as stage 1 by visual inspection and evolved to stage 3/4 within days. It is possible that a proportion of the stage 1 ulcers in this study were misclassified and that they were really deep tissue injuries given how quickly these ulcers evolved over time. Other skin lesions with color change may reflect different dermatological diagnoses including; moisture associated dermatitis, fungal or yeast intertrigo or other dermatological conditions.

By eliminating the current numerical classification system and documenting the partial thickness and full thickness depth along with the appropriate physical findings (location, size, base, exudate, and margins), healthcare providers may prevent misleading communication.

Modified with permission from Dr. Diane Krasner, one of the authors of the Shifting the Original Paradigm article published in Advances in Skin and Wound Care December 2011.

This is only one of the controversial areas covered by this article. Get in on the shifting thinking about pressure sores by learning from one of the authors of this landmark statement. Dr. Krasner explores these and other controversies in an all new multimedia course that will take place on February 27 and March 5. Set aside the day of February 27 to join us for an interactive course, and complete the course the evening of March 5. Reserve your spot today. Can’t join us on either date? Get the on demand recordings of Pressure Sore Case Analysis and Reports here.

When you register for the course, you will receive 10 articles loaded with essential information about pressure ulcers, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized optional critique of your report. Sign up for Pressure Sore Case Analysis and Reports here. Early bird pricing ends February 13.

Skin changes at the end of life – appearance
Also known as Kennedy Terminal Ulcers, these are a specific subgroup of pressure ulcers that some individuals develop as they are dying. They are usually shaped like a pear, butterfly, or horseshoe, and are located predominantly on the coccyx or sacrum (but have been reported in other anatomical areas). The ulcers are a variety of colors including red, yellow or black, are sudden in onset, typically deteriorate rapidly, and usually indicate that death is imminent.

Physiologic changes that occur as a result of the dying process (days to weeks) may affect the skin and soft tissues. These changes may manifest as observable (objective) changes in skin color, turgor, or integrity, or as subjective symptoms such as localized pain. Here is the medical legal issue: clinicians assert that these changes can be unavoidable and may occur with the application of appropriate interventions that meet or exceed the standard of care.

Causes of skin changes at the end of life
When the dying process compromises the homeostatic mechanisms of the body, a number of vital organs may become compromised. The body may react by shunting blood away from the skin to these vital organs, resulting in decreased skin and soft tissue perfusion and a reduction of the normal cutaneous metabolic processes. Minor insults can lead to major complications such as skin hemorrhage, gangrene, infection, skin tears and pressure ulcers that may be markers of SCALE.

Are skin changes at the end of life preventable?
Skin changes at life’s end are a reflection of compromised skin (reduced soft tissue perfusion, decreased tolerance to external insults, and impaired removal of metabolic wastes). When a patient experiences SCALE, tolerance to external insults (such as pressure) decreases to such an extent that it may become clinically and logistically impossible to prevent skin breakdown and the possible invasion of the skin by microorganisms. Compromised immune response may also play an important role, especially with advanced cancer patients and with the administration of corticosteroids and other immunosuppressant agents.

Skin changes may develop at life’s end despite optimal care, as it may be impossible to protect the skin from environmental insults in its compromised state. These changes are often related to other cofactors including aging, co-existing diseases and drug adverse events. SCALE, by definition occurs at life’s end, but skin compromise may not be limited to end of life situations; it may also occur with acute or chronic illnesses, and in the context of multiple organ failure that is not limited to the end of life.

Dr. Diane Krasner

Legal perspective on skin changes at end of life
What you’ve read is the medical perspective. There are attorneys who dispute the existence of SCALE and see it as a handy way for a facility to defend the development of a pressure sore. Join the controversy on February 27 and March 5, 2012. Dr. Diane Krasner provides an intimate and detailed look at pressure ulcer causes and cures in a multimedia course that will take place on February 27 and March 5. Set aside the day of February 27 to join us for an interactive course, and complete the course the evening of March 5. Reserve your spot today. Can’t join us on either date? Get the on demand recordings of Pressure Sore Case Analysis and Reports here.

When you register for the course, you will receive 10 articles loaded with essential information about pressure ulcers, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized optional critique of your report. Sign up for Pressure Sore Case Analysis and Reports here. Early bird pricing ends February 13.

Amanda Trujillo was guilty of doing what nurses are trained to do – to be a patient advocate. We are required according to our ethical codes to speak up on behalf of patients. The physician was obligated to explain the risks and benefits and alternatives of the surgery. Somewhere along the way this process got derailed, and the patient was left not understanding the impact of what she was facing. Shame on the doctor for not seeing his patient as a person instead of a case, and shame on Banner Health for bowing to the pressure to terminate Amanda for doing her job. Shame on everyone for labeling Amanda as being in need of a psychiatric evaluation.

I have been reviewing medical and nursing malpractice cases as a legal nurse consultant for 23 years. I am a past president of the American Association of Legal Nurse Consultants. When nurses do NOT speak up to question doctor’s orders, to advocate for their patients, to report changes in condition because they are intimidated, BAD outcomes can result. All of us are patients; all of us need advocates to help us make decisions. Amanda fulfilled that role. The nightmare that has descended on her head is horrifying.

Here is my letter to the Arizona Board of Nursing
Arizona State Board of Nursing
4747 North 7th Street, Suite 200
Phoenix, AZ 85014-3655
602-771-7800 Phone
602-771-7888 Fax
arizona@azbn.gov Email

http://www.azbn.gov/Default.aspx

To whom it may concern,
In the case of Amanda Trujillo, RN, as I understand the details of her case, she was doing her job. She was upholding her obligation to be a patient advocate. I have been a legal nurse consultant for 23 years, a past president of the American Association of Legal Nurse Consultants, and editor of Nursing Malpractice, Fourth Edition, 2011, published by Lawyers and Judges Publishing Company. I have seen cases in which patients have been injured by incompetent physicians.
Amanda’s case needs to be looked at in the bigger issue of patient care. Yes, she educated her patient to help her decide on the best option for her. But what happens to other Arizona nurses who need to educate their patients if that education results in incurring the wrath of a physician? When the nurse is silenced, afraid to speak up, afraid to advocate for the patient, some very bad results can occur. Your disciplinary action against Amanda would send a message to nurses that they should not speak up. Your failure to support her would undermine the very necessary safety net that nurses provide.

Ten years ago, five years ago, the Arizona Board of Nursing could have taken action against Amanda with very little notice from the world outside your borders. Now, through social media, you have a spotlight on your actions. We watched the case of the nurses in Texas and rallied behind them. You can’t hide. Do the right thing and drop the complaint against Amanda. Allow her to resume her life.
Best regards,
Patricia Iyer MSN RN LNCC
Past president of AALNC

Read more about Amanda below and at this link: http://www.nursefriendly.com/amanda/

BEFORE THE Arizona STATE BOARD OF NURSING

In the Matter of Registered Nurse License No. RN137552 issued to:

Amanda Trujillo,

Respondent. )

RN/LPN INVESTIGATIVE QUESTIONNAIRE

DESCRIPTION OF EVENTS

(Nurse Practice Consultant, Ann Schettler)

Respondent Amanda Trujillo, by and through undersigned counsel, submits this Description of Events in response to a complaint filed against her in (date omitted) with the Arizona State Board of Nursing (“Board”) by (“facility”).

Description of Relevant Events

The allegations contained in the complaint arise from events that occurred on (omitted), when Ms. Trujillo was caring for a patient with end stage liver disease in the (unit at facility). Ms. Trujillo had been a registered nurse with (facility) for approximately six months prior to the date of the alleged conduct and she normally worked the night shift from 7 a.m. to 7 p.m.

After assessing and communicating with the patient, Ms. Trujillo’s evaluation led her to believe that the patient did not fully understand what she had consented to when (pt) agreed to go forward with an intensive transplant evaluation scheduled to begin at (facility) the following day. Based on her nursing assessment, Ms. Trujillo gathered patient education materials and spoke with the patient regarding the transplant evaluation, the waiting period and the commitment needed in following a lifelong self-care regimen. After their discussion, the patient expressed a desire to learn more about hospice care because (pt) was uncertain she was willing to take the necessary steps to maintain a successful organ transplant. Thus, the patient inquired into whether (pt) could speak with a hospice representative. Ms. Trujillo then placed an “order” for a case management consult with a hospice representative. Ms. Trujillo did not believe that requesting a case management consult was a medical order requiring physician permission; she believed the consultation was for educational purposes in order to give the patient a broad understanding of her options.

As a result of the additional information given by Ms. Trujillo, the patient determined (pt) did not want to go through with the liver transplant evaluation or resulting transplant procedure. When the doctor treating the patient found out about the patient’s wishes to forgo the evaluation he was unhappy that the patient had changed (pts) mind and determined that the education given by Ms. Trujillo was the underlying cause of the patient’s change of heart. He accused her of going beyond her scope of practice by entering a physician order without permission (“ordering” the case management consultation). As a result of the accusation, Ms. Trujillo was placed on administrative leave by her nursing director, and was eventually terminated by (facility).

Ms. Trujillo believes she was well within her scope of practice to assess the patient’s understanding of (pts) plan of care. She was not acting outside her scope of practice by educating the patient (deferring all questions outside of her scope to the medical team), once she determined the patient had a gross misunderstanding of what (pt) had agreed to participate in. Ms. Trujillo believed that the case management “order” she placed on the patient’s behalf was not a medical order that needed physician permission. Each step of the treatment provided by Ms. Trujillo to the patient will be analyzed below.

Patient Assessment

It is standard practice for Ms. Trujillo to ensure her patients understand their medications, plan of care and treatments. While fully reviewing the patient’s medical record Ms. Trujillo read a progress note entered by the patient’s primary care physician from earlier in the day that noted a “transplant evaluation is the only viable option outside of Hospice.” Utilizing the standard nursing process of patient assessment (assessment, diagnosis, planning, intervention, evaluation), Ms. Trujillo asked the patient a number of open-ended questions regarding (pts) hospital stay, medications, liver disease, procedures, etc. Ms. Trujillo asked the patient if (pt) had received any information or teaching regarding the proposed transplant evaluation. The patient, to Ms. Trujillo’s surprise, responded that (pt) did not understand (pts) disease, plan of care or what a transplant evaluation entailed. The patient asked Ms. Trujillo if she could provide some information regarding the disease and any less invasive choices that would allow (pt) to go home and be with (pts) family. Based on this request Ms. Trujillo determined the patient had a knowledge deficit regarding (pts) disease and the choice to receive palliative care.

Patient Education

Having assessed the knowledge deficit related to the patient’s routine medications, disease process, associated tests and procedures, the plan of care for transplant evaluation and palliative care options, Ms. Trujillo proceeded to print out patient educational material from facility’s website that addressed those areas. Additionally, she printed out education materials from facility’s transplant website pertaining to what to expect during a transplant evaluation and what to expect after a transplant. Ms. Trujillo also provided materials related to hospice care per the patient’s request. Ms. Trujillo, concerned about the patient’s lack of understanding of (pts) treatment regimen and the option for comfort care, discussed her education of the patient with her clinical manager, (omitted), who readily supported Ms. Trujillo’s plan of care and interventions.

Ms. Trujillo and the patient reviewed the materials over the course of the night. After a full review of the materials the patient stated, “Had I known everything I would have to go through and the commitment I would have to make, I would not have agreed to the transplant evaluation.” The patient inquired into whether there was anything else (pt) could do besides enduring more tests, procedures or surgeries. Ms. Trujillo then explained hospice care services and the differences between symptom relief care and end of life care. The patient expressed serious concern that (pt) would not be able to commit to an extensive aftercare regimen following the transplant by stating “at this stage in (pts) life (pt) just wanted to be around family.” The patient requested to visit with a representative from hospice in order to ask some questions and gain additional information that would assist (pt) in making a more informed decision regarding (pts) course of care.

Ms. Trujillo placed a note in the chart pertaining to the assessment of knowledge deficit, the specific education provided and the palliative care discussion, in addition to, the patient’s request to see a case manager from hospice. She used the SBAR (Situation, Background, Assessment and Recommendation) format of report required in (facility) policy when she handed off care of the patient to the dayshift nurse, alerting the nurse that the patient requested more information prior to being transferred to another facility for a transplant evaluation. She also alerted the dayshift nurse that there was a nursing note in the record for the doctor to read that detailed what occurred over the course of Ms. Trujillo’s shift with the patient.

Case Management Consult

As a relatively new nurse to (facility), Ms. Trujillo self-educated in order to work within facility’s policies and procedures. She found no specific policy or procedure regarding end of life care that prohibited her from obtaining case management consultations for her patients. She also could not find any policy or procedure that gave a formal definition of a “physician order” or what nurses could order and what they could not. In fact, Ms. Trujillo had ordered hospice consultations for her patients on numerous occasions prior to this incident without any objections from other physicians or (facility) administration. She entered the “order” with a note stating, “per patient request, patient wants to visit with hospice representative for more information.” In fact, the computer system in place at (facility) allows her to click a box that further specifies “Nurse Ordered,” which she did on this occasion.

The only reason Ms. Trujillo’s actions turned into allegations of unprofessional conduct is because the primary care physician on this case, The Dr. initiated an angry public display when he found out that the patient had changed (pts) mind regarding the transplant. Ms. Trujillo was surprised when the nursing director, went so far as to tell Ms. Trujillo that the physician was angered because she had, “messed up all of the work they had done, and that the doctors were nowhere near going down the hospice route.”

Conclusion

This was not a medical order. This was a nurse trying to help a patient become better informed about a life changing procedure and (pts) right to choose what direction (pts) care would go. Ms. Trujillo’s actions were well within her scope of practice and she conscientiously kept her line of teaching within the boundaries of her scope of practice by taking care to utilize the proper channels to obtain patient teaching materials and advising the patient to ask the doctors about more complex questions she was unable to answer as a registered nurse.

The patient had the absolute right to self-determination regarding her course of treatment, as illuminated in Senate Bill S. 1052, the Bipartisan Patient Protection Act, after receiving additional information regarding her disease. Ms. Trujillo, working within her scope of practice and the nurse’s code of ethics, honored and protected that right when she abided by the patient’s requests to the best of her ability.

Accommodating a patient’s request for a consultation with a hospice case manager does not require a physician’s order. No medication was requested, no equipment was needed, and no procedures were required. A patient simply wanted to speak with an expert regarding her options for comfort care and end of life care, so that (pt) could make the best decision about (pts) future.

It is standard knowledge that the Cerner electronic health records system in place at (facility) contains a box that states, “Nurse Ordered.” Why would this box exist if nurses were never allowed to “order” anything? The Complainant contends that Ms. Trujillo overstepped her scope of practice by ordering the consult; however, it is standard practice of the hospital to allow nurses the freedom to do the exact thing alleged in the Complaint.

Ms. Trujillo was allowed to order case management consults on numerous occasions prior to this and was never told by the hospital that this practice was not allowed or outside the scope of her practice. It is apparent that the hospital is simply trying to appease and placate an angry physician by filing this Complaint against Ms. Trujillo.

She looks forward to discussing this matter with the Board, if necessary, and hopes to conclude this matter expediently.

SUBMITTED: July 11, 2011

ROBERT CHELLE LAW

By: ______________________

Robert Chelle

Attorney for Amanda Trujillo

****Amanda Trujillo’s response to this post:

Amanda Trujillo: Patricia i have seen your name before all this, like im supposed to know you for some reason—thank you for your wonderful support–having a veteran nurse such as yourself behind today snurses is an incredible gift

History
In 1987, Congress passed the Omnibus Budget Reconciliation Act (OBRA). This legislation set specific standards for all Medicare certified skilled nursing facilities including a detailed assessment of the patient that was linked to their plan of care. What came out of this legislation was the Resident Assessment Instrument (RAI). Don’t let all the acronyms confuse you. The RAI standardizes communication regarding the person’s medical problems and conditions both within the LTC facility and to outside healthcare providers. The RAI enables the nursing home to track changes in a patient’s status and evaluate their individualized plan of care. So, you can see how the RAI is a great place to start a medicolegal analysis.

Specific Documents of the RAI
• Minimum Data Set (MDS) provides a detailed assessment of the patient that is linked to that person’s individualized plan of care. The MDS includes information on people’s cognitive and functional abilities along with their physical condition. The MDS is a goldmine for a LNC. One of the best things about the MDS is consistency throughout all facilities in the United States. Of course, there is a twist to this. A revision of MDS – MDS 3.0 – was rolled out in late 2010 with an expanded section on skin conditions. It is critical to analyze cases according to the standard of care in place at the time of the alleged negligence. If the events took place in 2010, the new MDS 3.0 would not be applicable. Please refer to Angie Duke Haynes’ article devoted specifically to this new version of MDS.
• Resident Assessment Protocols (RAP) is the next step in the RAI. Based on the MDS, certain protocols are triggered. Think of these as “problems”. Included in these protocols are risk factors that prompt care planning. A RAP summary is part of the MDS. It is a checklist and includes which RAPs are triggered, date of assessment documentation and where that document is located in the record, i.e. speech therapy note. Again, this form is consistent among all facilities in the U.S.

• Care Plan – There is nothing new or different about a LTC care plan. Nurses in all specialty areas assess, plan, implement and evaluate based on the individual patient’s needs. The key in long term care is to review the care plan to ensure it is consistent with the MDS and RAP. As with all case analysis, the care plan is reviewed to ensure the nursing staff identified issues and appropriately provided interventions and evaluated those interventions.

Practice Pearls
• Educate yourself if this is a new area of nursing for you. Utilize resources such as National Pressure Ulcer Advisory Panel (NPUAP), Agency for Healthcare Research and Quality (AHRQ) Clinical Practice Guidelines, RAI User’s Manual and The Long Term Care Survey. Be careful to use resources during the time for which the alleged negligence took place.
• Compare the MDS to the RAPs and the care plan. Is the information consistent? Then compare the clinician progress notes including therapy notes. Note relevant inconsistencies in your analysis.
• Were changes in function or cognitive status identified appropriately? Was the plan of care adjusted based on the change in status? Where is the evidence to support or refute the standard of care being met?

Dana Jolly, BSN, RN, LNCC, is Principal of Jolly Consulting, LLC.

To learn more about these specialty documents and to create your own long term care case analysis, please join Angie Duke Haynes, Pat Iyer and me for a multimedia course on writing skills and long term care case analysis on February 1 and 8, 2012.

Reasons for nonhealing wounds
For patient wounds that do not have the ability to heal, the approach is different. These individuals with the inability to heal (nonhealable wound) may be due to inadequate blood supply and/or the inability to treat the cause or wound-exacerbating factors that cannot be corrected. There may be systemic disease, nutritional impairments or medications that delay or inhibit healing. When a healable wound does not progress at the expected rate, a chronic and stalled wound results. These wounds are more prevalent in older adults and are attributed to the aged skin and comorbidities, such as neuropathy, coexisting arterial compromise, edema, unrelieved pressure, inadequate protein intake, coexisting malignancy, and some medications. Persistent inflammation may be the cause of a stalled wound and in some cases may not be correctable. The presence of multiple illnesses in some older adult patients implies that healing is not a realistic end point.

The second category, a maintenance wound, is when the patient refuses the treatment of the cause (eg, will not wear compression) or a health system error or barrier (no plantar pressure redistribution is provided in the form of footwear or the patient cannot afford the device). These may change, and periodic re-evaluation may be indicated.

Expected healing time for wounds
Chronic wounds are often recalcitrant to healing, and they may not follow the expected pathway that estimates a wound should be 30% smaller (surface area) at week 4 to heal in 12 weeks.

Chronic wounds: Medical legal assumptions
In the medical legal world there may be an assumption that most if not all wounds can be healed with proper care. In the medical world, what percentage of wounds are considered nonhealable? In a study of 173 wounds, 70% were considered healable, 25% were considered maintenance, and 5% were considered nonhealable including skin changes at life’s end.

Modified with permission from Dr. Diane Krasner, coauthor of Special Considerations in Wound Bed Preparation 2011, an Update, Advances in Skin and Wound Care, September 2011

Dr. Diane Krasner

When you register for the course, you will receive the full article quoted from here, plus 9 additional articles, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized critique of your report. Sign up for Pressure Sore Case Analysis and Reports.

One of the most mystifying parts of the nursing home chart is the Minimum Data Set (MDS). The MDS is a standardized instrument used to assess all nursing home patients. It is a comprehensive assessment of the resident’s physical and functional abilities and cognitive status and includes indicators of delirium, fall history, diagnoses, wounds, nutritional status, restraint use, continence status, and more. The nursing and therapy notes and other documentation should be reviewed to ensure the information in the MDS is accurate.

Depending on the timeframe for the care being reviewed, the chart may contain an MDS that may be either version 2.0 or 3.0. After extensive review, the Federal government released the 3.0 version on October 1, 2010. The Resident Assessment Instrument (RAI) now consists of the Minimum Data Set (MDS) 3.0, the Care Area Assessment (CAA) Process, and the RAI Utilization Guidelines. The MDS 3.0 was refined to include many changes including, but not limited to, a focus on pain assessment and discharge planning, when assessments should occur, some changes in coding, and the use of Care Area Triggers (CATs) rather than Resident Assessment Protocol (RAPs). The MDS 3.0 focuses on resident participation through multiple interviews. The “look back period”, the time frame the MDS assessment is based upon, is seven (7) days for all areas unless otherwise noted on the assessment.

There are 20 CAA’s that can be triggered by the MDS responses. The identified triggers are used as a guideline for development of the individualized plan of care. The staff may override the trigger or decide to proceed and create a plan of care. For example, nutritional status may be triggered due to recent weight loss. However, the staff may override the trigger by indicating a recent history of bilateral above the knee amputations, thus justifying the recent weight loss or less than ideal body weight status. The CAA’s should be reviewed to ensure that all potential risks have been appropriately triggered and addressed in the plan of care.

While the Plan of Care (POC) is not paperwork specific to long term care, it is a very critical document and must be closely reviewed to ensure every risk unique to that resident has been addressed and that the POC is individualized to the specific needs of that resident. The care plan is a dynamic tool that should be updated as the needs of the resident change. For example, if the resident is at risk for falls and the goal indicates the resident will have no falls with injury within the next 90 days and that resident does indeed fall and sustained injury, the plan of care must be updated. You should expect to see new interventions to prevent falls.

Therapy documentation is critical to long term care cases. When a resident is involved in PT, OT or ST you will find frequent documentation which can be crucial, especially when there are few nursing and physician notes. Therapy notes will usually describe the resident’s functional ability, level of pain, subjective statements, cognitive status, and safety recommendations. Always be sure to review the therapy records thoroughly and compare these assessments to the nursing notes, physician notes, MDS, and care plan. Likewise, important information may be found in the social services notes as documentation regarding discharge plans, family concerns, and social history is likely recorded in this section.

Don’t allow your lack of familiarity with long term care records hold you back from an interesting case review. Your knowledge of the records outlined above will provide you the ability to thoroughly understand the residents’ needs and determine whether they were met. This information is just a brief overview of a few of the records. However, part of being successful is self educating and knowing how to find the information you need. Identifying a long term care nurse that you can call with questions as needed might just provide you with the added confidence needed to say “Yes” when asked to review a nursing home case. To learn more about record reviews and how to WOW your clients check out this information on how to polish your writing skills.

Angie Duke-Haynes, RN is President of Premier Medical Legal Consulting, LLC, co-owner of Legal Nurse Consulting Institute, LLC and co-presenter of an all new webinar on polishing your writing skills.

Pain Scales Use with Pressure Ulcers
A variety of pain scales are used to measure that which is subjective. The universally accepted measurement techniques are the utilization of visual analog scales (10-cm line with no pain at one end and worst possible pain at the other end, and the patient places an ‘‘x’’ at the appropriate point), Faces Pain Scale (various levels of happy and sad faces), or the numerical rating scale. The numerical rating scale asks if the patient has any pain on a 0- to 10-point scale with the anchors that 0 is no pain, 5 is the pain associated with a bee sting, and 10 would be the amount of pain experienced by slamming the car door on your thumb. Even in patients who cannot respond verbally, such as those with dementia, pain still needs to be assessed. There are pain scales for these patients that rely on nonverbal clues such as facial grimaces and pupil dilatation. (Assessment of pain for people with dementia can be found at www. hartfordign.org.)

Causes of Painful Pressure Ulcers
Pain levels should be recorded before dressing change, during dressing change, and after dressing reapplication. Krasner has defined wound associated pain at dressing change (intermittent and recurrent) versus incident pain from debridement or the persistent pain between dressing changes. Woo carried the Krasner concept further and demonstrated that anxiety and other patient-related factors could intensify the pain experience.
The Wound Associated Pain Model of Woo and Sibbald defines pain from the cause of the wound as often being persistent or present between dressing changes and distinguishes this pain from the pain associated with local wound care components (dressing change, debridement, infection, lack of moisture balance). All of these factors can be modified by patient-centered concerns, including previous pain experience, anxiety, depression, mobility and awareness or lack of comfort with the setting, and the procedure or treatment plan. Pain is an under-recognized and undertreated component of chronic wound care that has been demonstrated to be more important to patients than healthcare professionals. Causes of pain at dressing change include the dressing material adhering to wound base, skin stripping from strong adhesives, and aggressive trauma from cleansing technique (eg, scrubbing with gauze).

Many patients also express chronic persistent pain between dressing changes even at rest. A systematized approach should examine other systemic and disease factors that may play a role in precipitating and sustaining persistent wound-related pain. Common systemic factors are bacterial damage from superficial critical colonization or deep and surrounding compartment infections, deep structural damage (eg, acute Charcot foot in patients with diabetes), abnormal inflammatory conditions (eg, vasculitis, pyoderma gangrenosum), or periwound contact irritant skin damage from enzyme-rich wound exudate.

Impact of Pressure Ulcer Related Pain
Bill has a Morphine pump in his abdomen to deal with his pain. He takes supplemental Morphine by mouth. There are times he sleeps all day and is awake all night. The impact of chronic unrelenting pain can be devastating, eroding the individual’s quality of life and constituting a significant amount of stress. Increased levels of stress have been demonstrated to lower pain threshold and decrease tolerance. The result is a vicious cycle of pain, stress/anxiety, anticipation of pain, and worsening of pain. Increased stress also activates the hypothalamus-pituitary-adrenal axis, producing hormones that modulate the immune system compromising normal wound healing. Medications including nonnarcotic for moderate pain and narcotic analgesics for moderate to severe pain are required to treat severe pain as outlined below. A consult from a pain and symptom management team may be considered. Comprehensive management should also include careful selection of atraumatic dressing, prevention of local trauma, treatment of infection, patient empowerment, stress reduction, and patient education.

Modified by Pat Iyer with permission from Dr. Diane Krasner, coauthor of Special Considerations in Wound Bed Preparation 2011, an Update, Advances in Skin and Wound Care, September 2011

Dr. Diane Krasner

When you register for the course, you will receive 10 articles loaded with essential information about pressure ulcers, the opportunity to participate in the course and receive the transcripts, plus a substantial discount off two programs: Take the Terror of out Testifying and Negative Pressure Wound Therapy. Receive an individualized optional critique of your report. Sign up here for Pressure Sore Case Analysis and Reports.

1. Striking the wrong key
Relying on the computer to function as the only proof reader of your LNC report is sure to miss a few common typographical or grammatical errors. An example I frequently see is the wrong word being typed, i.e. “form” when “from” should appear. A lack of attention to detail is guaranteed to have your client second guessing his request to have you review the critical evidence in his case.

2. Blind side your client
Do not include any references: source document, Bates numbers, literature citations. You don’t want your client to easily find the critical document or the article that supports the case theory. Attorneys really do want to search through all those medical records themselves.

3. One and done
Just provide the facts and your conclusion. Don’t include recommendations for the next steps the client should take. After all, the report speaks for itself. Attorneys, being familiar with the provision of health care, can easily identify just the specialty needed for an expert review. All attorneys understand the difference between a diagnostic radiologist and an interventional radiologist, for example.

4. Missing the point
Make your conclusion hard to find. Place it anywhere but the beginning of your report. Attorneys love to read the whole report before they learn what your conclusions are. Placing your conclusion at the beginning of your report with emphasis formatting would make the attorney less inclined to read your entire report, something to be avoided at all times.

5. TMI*
When in doubt, include it. It is important the attorney is made aware of all potential breaches in the nursing standard of care regardless of the relevance to the allegations.

* too much information

Dana Jolly, BSN, RN, LNCC is president of Jolly Consulting, LLC, a national legal nurse consultancy. She is a published author and frequent lecturer on legal nurse and clinical topics. To learn more about what you can do to present a polished, accurate report, join Angie Duke-Haynes, Pat Iyer, and Dana Jolly on February 1 and 8, 2012 for a webinar course, Polish Your Writing Skills. Early bird price discount ends January 15, 2012. Order now to save.