I tell everyone that long-term care is the toughest arena for a wound consultant. However, it can also be the most rewarding. The focus of this month's blog is to give you an inside look of what really goes on in nursing homes versus other health care settings.

Long-term care facilities have it tough: annual state surveys, complaints, high turnover in staff – you name it. This is where I spend most of my time educating and building wound programs. Every pressure ulcer (injury) is investigated. Any minor discrepancy can throw a red flag to surveyors. The goal is to be "state ready." Nursing homes tagged with citations are no joke. They may experience very high fines, reimbursement can be stalled, or doors can be closed.

I recently worked in a facility that had several immediate jeopardy citations for pressure ulcers. Many of you might automatically think it was due to neglect. This was not the case. Documentation discrepancies are what created the mess. Gaps in education are usually the most common cause, and like pressure ulcers, you must remove the cause for them to heal. Ongoing education is imperative in managing a skin and wound program in ANY setting. This is where I come in!

Starting the Building Blocks of Wound Education

When I walked into the facility on my first day, the staff was very warm and welcoming. I felt the compassion toward the residents. The administrator was very involved, and was on the floor daily checking on the staff and residents. I walked up and down the halls and observed most of the day before digging into the electronic medical record system. I saw nurses and nursing assistants hustling in the hallways for meal times, doing check and changes, filling ice pitchers, charting, and more. This particular facility also had two shower aides. I was impressed! I knew they would be my front runners. There had been several DONs—and wound nurses, but no "true" experience—resulting in poor leadership. I also noticed a barrier between the nurses and nursing assistants, so I knew I had a lot of work to do to bring everyone together.

Over the first few weeks, I started the education process: skin assessments, in-services, implementing simple protocols, hands-on care with the nursing assistants, audits, building team spirit, all along with showing appreciation for their hard work. I immediately started noticing the difference in attitudes and the continuity in care.

Wound documentation in this facility was a bear... Poor head-to-toe skin assessments, missing pressure ulcers on admission, making it seem as though they weren't monitoring the wounds at all. If you didn't document it, you didn't do it – you know the saying. The other problem: there were too many hands in the pot (so to speak). I always teach the nurses to describe what they see. Paint the picture. There should be one nurse to stage pressure ulcers. This will minimize discrepancies.

The facility also had a provider documenting in the EMR system, followed by no comparative documentation. This led to one discrepancy after another: different wound staging, tissue types, treatments, and progress status. This is a big problem during the state survey process. The state surveyors automatically put this facility under a microscope and the citation situation snowballed fast. The community pressure ulcers ended up being focused on as well. The morale in the facility then started to suffer.

The good news is that we are now a month in since I started consulting there. I honestly had tears on Friday walking out of the facility. WE, as a TEAM, have cut the number of pressure ulcers and moisture-associated skin damage in HALF! I feel the team spirit in the air. The state survey plan of correction is coming up in the next few weeks, and I feel confident that this facility will do great. I am so proud of every person on this long-term care facility's team. I helped educate and empower the staff, but they are doing all the work – TOGETHER.

About the Author
Cheryl Carver is an independent wound educator and consultant. Carver's experience includes over a decade of hospital wound care and hyperbaric medicine. Carver single-handedly developed a comprehensive educational training manual for onboarding physicians and is the star of disease-specific educational video sessions accessible to employee providers and colleagues. Carver educates onboarding providers, in addition to bedside nurses in the numerous nursing homes across the country. Carver serves as a wound care certification committee member for the National Alliance of Wound Care and Ostomy, and is a board member of the Undersea Hyperbaric Medical Society Mid-West Chapter. She is the first LPN to be inducted as an Association for the Advancement of Wound Care (AAWC) speaker.