Jump to content

Does a pressure ulcer = incident report???

Posted

Has 3 years experience.

So the state was called into our facility this week to invesitgate a complaint. General nursing staff isnt privy to what was investigated or found but usually when something is 'substantiated' the facility must come up with a plan of change to correct whatever the problem was found to be. The plan of change this time was to require nursing staff to fill out an incident report and a QI report everytime a pressure ulcer or other 'preventable' skin occurance is discovered. Im not one to complain but as the facilities only weekend treatment nurse (200+ bed SNF) thats a heck of a lot of paperwork (in addition to the weekly flowsheet that monitors changes to said wound, RP contact sheet, doctors book, etc). I was just wondering, do any other facilities fill out incident reports and QI reports for pressure ulcers? Does that even make sense?

MomRN0913

Specializes in ICU.

When a patient is admitted with a stage 3 or stage 4 you write an incident report When they acquire a stage 3 or stage 4 during their stay you must write an incident report.

iceprincess492

Has 12 years experience.

OUr company requires an incident report for any new skin area: bruise, skin tear, pressure or vascular area. If they are admitted with skin problem it is documented but no incident report required

loriangel14, RN

Specializes in Acute Care, Rehab, Palliative.

We don't fill out an incident report, we just chart it.

We fill out an incident report where I work for any new skin issues including pressure ulcers. If they are admitted with the problem then it is just charted on.

KittyLovinRN

Specializes in Pulmonary, Lung Transplant, Med/Surg. Has 5 years experience.

We write incident reports for pressure ulcers on admission, transfer, and ones that are created on our unit. We also take pictures of each and every one for the chart..ESPECIALLY ones from outside the hospital

ckh23, BSN, RN

Specializes in ER/ICU/STICU. Has 6 years experience.

In my hospital every pressure ulcer requires an incident report to be filled out and the wound nurse to be contacted. I think in the hospital it has a lot to do with reimbursement because medicare will not pay for ulcers developed in the hospital and the hospital has to eat the cost of treating the pressure ulcer.

CoffeeRTC, BSN, RN

Has 25 years experience.

OUr company requires an incident report for any new skin area: bruise, skin tear, pressure or vascular area. If they are admitted with skin problem it is documented but no incident report required

This is what we do.

Why would you have to fill one out for an admit? They are new and admitted with it and it fall under what you are treating them for?

RNChristy

Specializes in Telemetry, ICU/CCU, Specials, CM/DM. Has 14 years experience.

When I worked at the hospital, we only filled out an incident report and QI form on newly acquired (while in the hospital) wounds. Any time a patient was admitted discharged, or transferred to another unit, we were required to take pictures of previous wounds. Especially with the new Medicare Guidelines, documentation is very important if a patient is admitted with any wound. CYA!

Christy

ayla2004, ASN, RN

Has 5 years experience.

We photoraph any pressure ulcer, skin tear or wounds, bruises on admission, or aquired.

We fill in incident reports for grade 2 pu on admission or if aquired, and all skin tears

wound care nurse referaal is pressure ulcer is garde 3-4

HDHRN

Specializes in LTC, HH, and Case Mangement. Has 8 years experience.

We fill out incident reports also. I have a resident who likes to shave her chin with one of those cheap plastic razors. She cut herself up pretty good last night and b/c she's on coumadin, it was hell tryin to stop it. :uhoh3: So I told the aids to make sure they keep an eye on her, we really oughta just throw it away. I did complete the incident report and faxed the doc, just so he was aware and to cover my ass.

A pressure ulcer is not an incident report, although your facility should have an investigation conducted specific to how it originated. An incident means precisely that - something happened all at once, such as a fall, a bruise, etc. And residents on Coumadin getting ahold of razors.

CoffeeRTC, BSN, RN

Has 25 years experience.

A pressure ulcer is not an incident report, although your facility should have an investigation conducted specific to how it originated. An incident means precisely that - something happened all at once, such as a fall, a bruise, etc. And residents on Coumadin getting ahold of razors.

We actually have a section on our froms for skin issues and I think (I'm having a brain issue) it has a part for pressure areas?

Incident reports? Yes, if its a witnessed fall or they hit their head. All others: If I/we have time.

Biggirl71

Specializes in Med/Surg/Tele, Neuro, IMU.

Incident reports are important because they allow for trending of issues. So, if your patient is discovered to have something new; wound, abrasion, skin tear, etc. document it on an incident report. By doing so, you may enable the facility to purchase the needed equipment for good, safe patient care. If all skin issues are investigated and the investigation shows it's because the mattresses are old or bad, then you may find that they will purchase new mattresses. If you overwhelm them with documentation, you are not only advocating for your patients, you are advocating for your place of employment. If they arrive with the wound, careful documentation (not an incident report-unless you suspect abuse) keeps your facility from "owning" the wound. If they develop the wound while at your facility, an incident report is necessary.

MomRN0913

Specializes in ICU.

This is what we do.

Why would you have to fill one out for an admit? They are new and admitted with it and it fall under what you are treating them for?

In the acute care hospital I worked at, we had to do a incident report on a stage 3 or 4 upon admission. It needs to be proven and documented that it happened prior to arriving and not acquired. We did not take pics in the acute care hospital. In the LTACH, every ounce of skin breakdown is photographed, but incident reports don't have to be written out upon admission because the reason they are there is typically to heal the wound.

If you get admitted in the ICU for respiratory failure on the vent, you are not there for wound healing, so you better write it up to prove it wasn't acquired there.

It is required by CMS (Medicaid/Medicare) to track all Stage II and above Pressure Ulcers as Quality Indicators so your facility better be tracking them one way or another if they get get get any type of Medicare or Medicaid funds. Most places do receive money from those organizations in one form or another. The information is reported by your MDS nurse and the most efficient way to do that is via Incident Reports.

If a family member would report your facility because their loved one had an untreated pressure ulcer, the LTC facility would be in major hot water and subject to fines and loss of funding. A BIG DEAL.

So the answer is YES every single Stage II, III, IV or Unstageable Decubitus Ulcer has to be documented and tracked according to your facility's policy. (To cover MY license, I would always write an incident report.)