Nurses must identify residents at risk for skin breakdown and intervene early. CMS guidance states that the intent of pressure injury requirements is to prevent pressure ulcer/injury development, promote healing of existing wounds, prevent infection, and prevent additional pressure injuries.
Wound Documentation Should Include
- Location and wound type.
- Stage, if pressure injury.
- Size: length, width, depth.
- Wound bed tissue.
- Drainage amount, color, odor.
- Periwound condition.
- Pain.
- Signs of infection.
- Treatment completed per order.
- Resident tolerance.
- Provider/wound physician notification when indicated.
Prevention Measures
- Repositioning and pressure relief.
- Offloading heels.
- Moisture management.
- Nutrition/hydration monitoring.
- Incontinence care.
- Skin checks.
- Specialty mattress/cushion as ordered.
- Care plan update.