leaving patient in bed with wound

CapeCodMermaid, RN · May 19, 2008

Perhaps in your state it is one of the most frequently cited tags. It is NOT in Massachusetts. Of course they can cite you for pressure ulcers if the documentation isn't perfect, but again, it's not one of the 'hot' citations in this state.

Could you explain how you do a 'tissue tolerance test"? Do you use caliphers? In Massachusetts the assessment for skin breakdown potential is the Norton Plus. That's it.

noc4senuf · May 19, 2008

Tissue testing is completed by the floor staff. We post a chart in the resident's closet with pictures of the body on it. The first person will document how long the resident was in said position and the condition of the skin when moved, example.. clear, red, pink, etc., they also document how long they were in that position. The next time they are put into that position, if they were red the time before, then this time around they need to be checked 15 min earlier. this is done until a time is found that they can be turned/repos in a timeframe that they will not be red when checked. It also involves the use of the Braden scale and a risk assessment to identify those who are at risk for skin breakdown and the actors that may contribute to it. We complete this on admission, qrtrly, and with a sig change.

The comment about it being one of the most cited regs in the country has come from NADONA, and several other associations.

CoffeeRTC, BSN, RN · May 19, 2008

I have never seen a tissue tolerance test done in all of my 13yrs in LTC. I am only prn now, but have never seen mention of this in our facilities. (I am in PA).

Getting back to the OP. If there is no MD order, you are going to have to use your nursing judgment and also look into the care plan. Just because someone has a pressure sore, doesn't mean that they will never get out of bed for meals. There is alot of issues here. Fist look for an order, second ask PT/OT to eval for positioning if this hasn't been done already. They should be able to recoment a support surface for in and out of bed. Speech should also be involved if they need any adaptive equiptment or special diets. You will have to look at the resident and make a decision as to how the person eats better. This could change daily or shift to shift. Evaluate for pain too. Dietary should also be involved. Is this person getting hi protien meals? Dietary preferences, etc? Look at staffing that day too.....Is there enough staff to get this person in and out of bed in an acceptable time frame (no this shouldn't be used as an excuse not to do what is best for this person, but it is a reality)

Unless a wound is really bad and the resident is contracted so that getting out of bed would make the res more uncomfortable etc...they get out of bed for that short period of time and will normally go back to bed.

GradNurse...what happend? What are you doing with this resident?

noc4senuf · May 19, 2008

The following is from the State Opertions Manual (my bible) for LTC.

http://www.cms.hhs.gov/transmittals/downloads/R4SOM.pdf

This is F314 which the surveyors following when surveying buildings.

KyPinkRN · May 19, 2008

I work on a floor specializing in wounds, and care of patients with vacs in a hospital here in KY... I have never heard mention of any tissue tolerance test. We have a very thorough wound care department, mostly with advanced practice degrees. It seems to me that we would be missing something big if the tissue tolerance test was required. Not something my hospital takes lightly.

noc4senuf · May 19, 2008

KYPinkRN.... the guidance and regs are for LTC. Sorry for any confusion.

ktwlpn, LPN · May 19, 2008

It's funny how this thread went from a simple question to a "I'm smarter then YOU and here's why" thread.

To the OP-it's possible the CNA was taking advantage of you and leaving the resident in bed for convenience.You'll see this in LTC-you can do one of 2 things.If you think the resident is comfortable and safe in the bed let it go or after you are done your 3 hour med pass,treatments,charting etc you can look into the situation.Ask your supervisor for input.If it turns out you were taken advantage of you can always approach the cna and instruct him/her to get the resident out of bed.It can be difficult to earn the respect of staff if you are a pushover.Good Luck

CapeCodMermaid, RN · May 19, 2008

The following is from the State Opertions Manual (my bible) for LTC.
http://www.cms.hhs.gov/transmittals/downloads/R4SOM.pdf
This is F314 which the surveyors following when surveying buildings.

There is NO mention of a tissue tolerance test anywhere in the regs. The word used is ASSESSMENT. In Massachusetts the accepted assessment tool is the Norton Plus. As long as we are all assessing our residents,especially on admission and readmission, and document the assessment and interventions, we'll be okay. And I quote:

"Unavoidable" means that the resident developed a pressure ulcer even

though the facility had evaluated the resident's clinical condition and

pressure ulcer risk factors; defined and implemented interventions that

are consistent with resident needs, goals, and recognized standards of

practice; monitored and evaluated the impact of the interventions; and

revised the approaches as appropriate. That paragraph is right out of the guidelines

noc4senuf · May 19, 2008

The only reason I have posted my past informational comments is d/t someone asking for the location it was listed.

F314 has in it a section called "Pressure Points and Tissue Tolerance" this was revised in November 2004. In this section it states, "The skin assessment should include an evaluation of the skin integrity and tissue tolerance after pressure to that area has been reduced or redistributed".

The section is 6 paragraphs long and ends with " It is, therefore, inportant for clinical staff to regularily conduct thorough skin assessments on each resident who is at risk for developing pressure ulcers.

I have come across the surveyors looking for this information in two different states. I am not the person requiring the extensive time it takes, they are. With all the recent "upgrades" in the SOM it has become a real chore to jump through the hoops the surveyors expect (especially when I am not an athletic person). :banghead:

asoonernurse · May 20, 2008

I believe this thread truly shows the many differing approaches used by nurses and assistants in LTC wound care methodology.

It also highlights the diversity of LTC facilities themselves. State regulations may vary in language and enforcement from state to state, and each facility may define protocols to follow, but in the end, it is the STAFF who works the trenches, and truly defines the CARE. :yeah:

Noc4senuf, I wish you well. I wish MY facility was as well run as yours. I'm jealous!

Good Luck!

Michael

The only reason I have posted my past informational comments is d/t someone asking for the location it was listed.
F314 has in it a section called "Pressure Points and Tissue Tolerance" this was revised in November 2004. In this section it states, "The skin assessment should include an evaluation of the skin integrity and tissue tolerance after pressure to that area has been reduced or redistributed".
The section is 6 paragraphs long and ends with " It is, therefore, important for clinical staff to regularly conduct thorough skin assessments on each resident who is at risk for developing pressure ulcers.
I have come across the surveyors looking for this information in two different states. I am not the person requiring the extensive time it takes, they are. With all the recent "upgrades" in the SOM it has become a real chore to jump through the hoops the surveyors expect (especially when I am not an athletic person).