Pressure Ulcers – Entry 1

Dear Diary:

I was hoping we were finally making progress with one of our resident Hattie, but now she has developed a deep tissue injury to her right heel. Hearing about an acquired pressure ulcer is never good news. At our interdisciplinary team meeting, we completed a root cause analysis of this pressure ulcer and here’s what we discovered:

  • When Hattie returned from the hospital nine days ago, the nurse completed the Braden Scale on admission day, and then another one seven days later. By day seven, Hattie had the deep tissue injury on her heel.
  • The results of both of these risk assessments showed that Hattie was at moderate risk for developing a pressure ulcer.
  • Hattie’s highest areas of risk are from her very limited independent mobility, walking infrequently even with assistance, eating and drinking poorly, and potential for shearing.
  • Hattie’s care plan and the nursing assistant (NA) assignment sheet did not indicate any preventive measures related to her identified risk factors besides the standard “reposition every two hours”.
  • Prevention measures were not implemented in her care plan upon completion of the Braden Scale (such as a dietary consult, implementation of support surfaces, off loading of heels and so on).

We also discovered there is no process in place to act on risk factors identified in the Braden scale risk assessment. We decided that this is the root cause of this pressure ulcer/deep tissue injury, and probably other acquired pressure ulcers we have! We are not blaming anyone for this oversight, as it seems to be an overall systems problem. What should I do next?

Signed, Donna


  • We have a certified wound care nurse and team at our facility that really focuses on education and does wound rounds routinely.

  • With this being a systems/process issue it will take longer to correct. The IDT needs to determine where the breakdown(s) are occurring. Is it a lack of education? Is it a lack of communication regarding the expectations? Or something else? Once you determine what part of the system is broken, you can begin to put it back together and educate/communciate what the expectations are with regard to putting interventions in place. Through this deeper look at the process you may also find other areas that need to be looked at as well.

  • When there is systems breakdown there is potential harm to everyone. When we identify a systems problem we cite ourselfs and treat it with a plan of correction. 1.Identify and improve care for those affected. Put immediate interventions in place. 2. Perform a baseline audit including head to toe assessment on all residents to assure there is no skin breakdown that we are not aware off. Review all Braden assessments and quantify how many display risk that are not care planned. 3. Once the data is collected, we do root cause and protocol review and make improvements to our system . We educate staff so all are aware of the Quality improvement implementation. 4. Develop a system for monitoring ongoing success. 5. Identify a date for completion and monitor. This might be a QAPI sub committee. PDSA may be used in test solutions prior to systems roll out.

  • We have the same problem as noted in Hattie’s case. We do our braden’s in a timely manner but do not look at risk areas to implement preventive measures. Nursing staff does well at doing body audit and looking for red areas and working on preventive measures with this. Dietary does nutritional consult but may not be within the firstr 24 hours. We also put turning and repositoning every 2 hours on group sheets but usually no other preventive measures as in Hattie’s case.
    We need to identify risk factors within the first 24 hours and discuss as IDT.

Share your nursing home perspective on this quality improvement issue.