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?