Geriatric bruising and what to do

[iamoph]

Hi all! Ill give you a bit of a back story then the questions. you can jump right to the questions if youd like.

BACK STORY:

We have a census that averages about 70. Of those 70 people 3/4 are incontinent or have periods of incontinence. We have very few who are independent with ADLs and transfers. more than half of the residents require full assist to get in and out of bed....which is: up for breakfast, in bed after, up for lunch, in bed after, up for supper, in bed after. Then, they are also gotten up for activities in between meals but have to be laid down to be cleaned up. Thats a lot of handling!!!!!!!!

Last DON got so sick of bruises that he started making up causes for them instead of actually investigating their cause. For instance, if a resident was on coumadin, he wouldnt even go assess the bruise. Instead, he'd say, "they're on coumadin they're going to bruise"

That would be the end of it.

The admin and D-op figured out what was happening and now the entire facility is freaked out over every single little bruise...to the point where even residents that get insulin injections are having multiple assessments and investigations done and they're being monitored for 72h after each bruise is found. There is no "official" written policy on how to handle bruises, just "events". We dont even remember how we used to do it before the DON screwed us all. It may sound stupid, but I swear the staff has a touch of PTSD over this issue. People will actually start sobbing if they realize they forgot to mention or chart a bruise that was found....even if its easily explainable!

I have found that this is causing more harm then good. the nurses time is now spent filling out paperwork and making notifications for even the tiniest of bruises. something has got to give.

HOW WE DO IT NOW:

bruise is found on mr. smith on lower abd. the nurse fills out report and calls the DON - even if its 3am - A fax is sent to the doctor and the family will notified of the finding of a bruise. Mr. Smith is added to the 72h assessment sheet where his vitals will be taken qshift for the next 3 days. The DON then has to "investigate" and sees that Mr. Smith gets insulin - usually in the abdomen - The DON then makes a nurse note that states this information and then writes a one page summary of findings to keep in the residents file.

OR

Mr. Smith had a fall on 10/12 that was unwitnessed. he was found on his L side and was placed on 72h neuro checks. on 10/16 there is a bruise noted to his L elbow. The paperwork is filled out and notifications made and hes back on 72hour monitoring from this bruise that was likely from the fall that he was already monitored for.

OR

Mr. smith takes coumadin and sits with hands in his lap at the dining table until his food comes. Hes constantly bumping things and then bruising because of his thin skin and coumadin use. Basically hes on neverending monitoring because we arent allowed to bubblewrap him.

QUESTIONS:

1) how do you handle bruises in your LTC facility?

2) If the bruise is found on an insulin dependent resident in an area that they get injections how is that handled?

3) Do the nurses investigate anything at all or just report it and let the DON do everything??

4) How many bruises does your facility typically have?

5) is there ever an instance where you would just put a nurse note in about the bruise and call it done?

6) Our D-op says we have too many bruises by any standard (she gets notified of all of them) how do we keep elderly people that are lifted and moved and dressed, etc. and have tissue paper thin skin from bruising without just throwing everyone in a padded room and never touching them??

[amoLucia]

I'm guessing that maybe the fact that your facility is so hyper-focused on bruising is that it may have been the subject of a DOH/Ombudsman investigation.

Your questions (except #6) all seem to focus more on the post-occurrence rather than prevention. There should be approaches that are care-planned and made known to all. And it should be an interdisciplinary approach probably best addressed thru some committee (a wound committee freq handles this).

What approaches have you already tried? I'm sure there is research out there to help.

[iamoph]

We've got everything under the sun careplanned!

For the people that ambulate on their own we have restoritve and therapy working with them on gait and balance. For those in wheelchairs we have restoritve and therapy working with them on w/c mobility.

We even have postures careplanned! (Mr. Smith sits with his hands under the table and has been observed bumping the edge of the table when when raising hands above table to eat: staff to encourage resident not to rest hands in lap while at dining room table)

It feels like the higher ups are making new rules whenever the mood strikes them. We were just told that careplans require a doctors order.... I've never heard that ever before..so, do they require a Dr order and I just missed that somehow?

We've done transfer check offs, and in services, and I've told staff to come get ME if they need assistance with a resident and can't find help.

[CapeCodMermaid, RN]

Care plans do NOT need an MD order. However, the doc is supposed to be in agreement with the plan of care. As the DON, I expected the nurses to investigate every bruise. If there was an abdominal bruise and the resident gets Lovenox, that's what we write on the event report. I've had to investigate nasty bruises...It's distressing to think someone is being abused. We use geriarms and gerilegs. Old people bruise and old people fall.

[bluegeegoo2, LPN]

I'm guessing that maybe the fact that your facility is so hyper-focused on bruising is that it may have been the subject of a DOH/Ombudsman investigation.

Your questions (except #6) all seem to focus more on the post-occurrence rather than prevention. There should be approaches that are care-planned and made known to all. And it should be an interdisciplinary approach probably best addressed thru some committee (a wound committee freq handles this).

What approaches have you already tried? I'm sure there is research out there to help.

I agree with the likelihood of there being POC in place.

I worked in a building that every single fall was an automatic Xray of the pelvis and bilat hips regardless of clinical findings. Was a pain but a POC is a POC so we complied.

[CapeCodMermaid, RN]

Facilities have wacky policies. I worked for a large company which wanted us to do a UA C&S after every fall. I argued against it. Sure, if they had other symptoms grab a urine, but many times the falls were observed...one lady tripped over another lady's wheelchair leg. It wasn't a UTI, it was an activities department who tried to cram people in the room. At least things should be based in reality. We had people who fell 5-10 times a year. If they had an x-ray every time they'd be glowing in the dark.

[iamoph]

Thank you all for your comments.

I have discovered that it IS corporate just making things up as they go. During a meeting one of the higher ups actually said to disregard what the state surveyer said (we had a surveyer in to clarify) and continue doing things like we've doing them. I want my residents safe but this is overkill and its actually hindering the care they receive. It may be time for a new job.

[amoLucia]

The sad thing is that despite all your facility's high-stepping, their bruise rate MAY NOT go down, but instead will remain unusually elevated.

I had a really wise instructor in my BSN Nsg Issues class. She pointed out that some statistics may not be really be unusually high compared to others in the facility. It was that some units just practiced better REPORTING all their occurrences, whereas some other units were less stringent with reporting/documenting.

At my very first job, every unit received statistical monthly/quarterly Falls/Safety reports. My unit ALWAYS ALWAYS had the highest falls rate. But I knew we reported EVERYTHING & ANYTHING resembling a fall. (When I floated, I learned some occurrences were just DEALT with - no Incident Reports.)

Sadly, your facility's aggressive reporting may be biting them in the butt when the Sate looks at the rate.