Does a pressure ulcer = incident report???

[optimist]

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?

[CoffeeRTC, BSN, RN]

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?

[LostInFugue]

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

[Biggirl71]

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]

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.

[fancyhen]

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.)