Improving Quality of Care Based on CMS Guidelines

Volume 3, Issue 4

Butterflies are Free:
Exceptional End of Life Care

Jumpstart Wound Healing



Forms and Tools:

Great Stategies to Improve Care

CMS Targets Psychosocial Outcomes
Insight on Organization & Balance from Author Julie Morgenstern


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Improving Quality of Care Based on CMS Guidelines
Editor Sue MacInnes, RD, LD Clinical Editor Margaret Falconio-West, BSN, RN, APN/CNS, ET, CWOCN, DAPWCA Clinical Team Cynthia A. Fleck, RN, BSN, ET/WOCN, CWS, DAPWCA, MBA, FCCWS Janet L. Jones, RN, BSN, PHN, ET, CWOCN, DAPWCA Barbara Leonard, MSN, RN, CWOCN, CWS Joyce Norman, RN, BSN, CWOCN, DAPWCA Elizabeth O’Connell-Gifford, RN, BSN, CWOCN, DAPWCA, MBA Carol Paustian, RN, BSN, ET, CWOCN, DAPWCA Amin Setoodeh, BSN, RN Jackie Young, RN, BSN, ET, CWCN, DAPWCA Wound Care Advisory Board Anne Blackett, MS, RN, COCN, CWCN, CPHQ, CNS Pat Emmons, RN, MSN, CNS, CWOCN Beatrice Etzel, MSN, APRN, BC, CWOCN Lynne Grant, CNS, MS, RN, CWOCN Pam McFarland, RN, CWCN, OCN Andrea McIntosh, RN, BSN, CWOCN, APN C.C. Monge, RN, MS, DABFN, CWOCN Susan Morello, RN, BSN, CWOCN Susan Wood, PhD, RN, WOCN

SURVEY READINESS Ask Molly CMS and Psychosocial Outcomes Healthy Skin Interview The Wait Is Over: CDC Introduce New Guidelines for Management of MDROs in Healthcare Settings 46 How Good Are You at Assessing Risk? Sharpen Your Skills with the Braden Scale 50 Managing Dementia-Related Incontinence 64 Documentation: Using the Best Words for You and Your Resident 13 14 22 28 20 34 55 56 TREATMENT Can a Cranberry a Day Keep UTIs Away? Chronic Wounds: Collagen Might Be the Answer Pressure Relief: A Concept of the Past Product Spotlight: Foam Dressings

Page 6

SPECIAL FEATURES 6 Butterflies are Free 32 Do It RIGHT! Joint Commission Releases Pressure Ulcer Prevention Video 42 Making Sense of Research Reports 68 Oh,Your Aching Back 79 What’s in a Name? 82 Healthy Skin Word Search 84 86 88 90 92 94 95 FORMS & TOOLS Functional Incontinence Incontinence Quality Improvement/Quality Assurance and Assessment Policy & Procedure Guidelines for Use of Overnight Brief Use Our Web Tools Butterfly Watch End of Life Care Plan

Page 14

Page 34

CASE STUDY 40 Use of Ionic Silver and Collagen to Reduce Bioburden and Promote Healing for Improved Quality of Life in a Complex Patient REGULAR FEATURES Letter from the Editor News Flash CE Crossword Puzzle: Collagen Dressings in Chronic Wounds Hotline Hot Topic
Page 68

© 2006 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060 1-800-MEDLINE (633-5463)

4 5 38 60

CARING FOR YOURSELF 72 PEP Talk from a Pro 80 Top Ten Time Management Tips

Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 700 dedicated sales representatives nationwide to support its broad product line and cost management services. For more information on Medline, visit our website,

Improving Quality of Care Based on CMS Guidelines


HEALTHY SKIN I Letter from the Editor


To continue to bring you the hottest information that will have the greatest impact on your job, we consistently reach out and interview your colleagues and administrators. In preparation for this issue, we asked nursing home DONs from all over the country, “What do you worry about the most when the state comes in for inspections?” Their top concerns were safety, pressure ulcers, compliance with incontinence/toileting plans and falls. To nursing home administrators we asked, “What concerns do you have about the upcoming Pay-for-Performance reimbursement?” Their answer … quality indicator ranking and the impact of survey results to P4P. Then, on December 12, 2006 Dr. Berwick, CEO of IHI (Institute for Health Improvement) announced that one of the new key platforms of IHI’s new 5 Million Lives campaign for hospitals was to prevent pressure ulcers. Aha! Pressure sores are on everyone’s list. Dr. Berwick underscored what you’ve known all along – hospitals and nursing homes are both stakeholders invested in improving quality of care. This edition of Healthy Skin is jam-packed with information on pressure sore prevention, assessment, treatment and ways to provide exceptional care. Let’s start with prevention. The Joint Commission (formerly referred to as JCAHO) recently released an educational program on the prevention of pressure soressee page 32 on how to “Do It RIGHT.” You can test your assessment skills using the Braden Scale and a simple case study. And be sure to read about treatment options, like collagen, that can jump start a challenging wound and new technology in foam dressings. We realize good skin care and prevention include other components such as residentcentered incontinence and toileting programs. Throughout Healthy Skin, you will find success stories, tricks and helpful hints to make your program work. An example of exceptional care, you don’t want to miss “Butterflies are Free” a feature article that demonstrates the impact exceptional care has on your staff, the resident and their family. Nina Willingham, administrator of Life Care Centers of Sarasota, Florida, reminds us about what health care is all about and how to make a difference in people’s lives. Finally, we close with something special just for you. We decided to try something new in this edition, a section we call “Caring for Yourself.” As a frontline provider, we know how much effort you put into caring for your residents – and your families. But, we all need to take time for ourselves, refuel, energize and get organized so we can perform at our best. We were so fortunate to be able to interview Julie Morgenstern (you may have read her column in O magazine or one of her numerous books on time management and organization). She has provided us with some insightful tips to help find that balance in life and make the most of our time. We hope you’ll enjoy it! Best Regards,

We all can agree that we should do things right…but it is our goal to make it hard for the healthcare worker to do things wrong.

Sue MacInnes




IHI Announces New Campaign
The Institute for Healthcare Improvement’s newest campaign, 5 Million Lives, aims to dramatically reduce incidents of medical harm in U.S. hospitals by challenging those hospitals to adopt up to 12 improvements in care in a 24-month period (ending December 9, 2008). In addition to the six interventions introduced in the 100,000 Lives Campaign, six new interventions were announced. They are: • Prevent methicillin-resistant Staphylococcus Aureus (MRSA) • Reduce harm from high-alert medications • Reduce surgical complications • Prevent pressure ulcers • Deliver reliable, evidence-based care for congestive heart failure • Get Boards on board For more information on the new campaign, visit

CPSC Sets New Mattress Flammability Standards
The Consumer Product Safety Commission has issued a flammability standard for mattresses as part of the Flammable Fabrics Act. All mattresses manufactured, imported or renovated on or after July 1, 2007 will need to conform to the new standard.The goal of the new requirements is to create mattresses that, in the event of a fire, generate a smaller size of fire with a slower growth rate, which in turn would reduce the possibility of flashover occurring.The Commission is estimating that the new standard could possibly eliminate 240–270 fire-related deaths and 1,150–1,330 fire-related injuries annually. For more information on the new standard, visit

CDC Releases New Guidelines on MDROs
The Centers for Disease Control and Prevention has released its long-awaited updated guidelines on multidrug-resistant organisms in healthcare settings. The guideline contains specific recommendations designed to halt the progressive increase in MDROs that began to be seen in the early 1990s. The guidelines contain two tiers of recommendations. The first tier includes general recommendations and the second details intensified interventions for use in the event that the first-tier recommendations are not effective. Each tier consists of the same seven control measures: administrative, MDRO education, judicious antimicrobial use, surveillance, infection control precautions, environmental and decolonization. For more on this topic, please refer to “The Wait Is Over: CDC Introduce New Guidelines for Management of Multidrug-Resistant Organisms in Healthcare Settings” in this issue of Healthy Skin or visit

Improving Quality of Care Based on CMS Guidelines


Butterflies are



By Nina Willingham, CNHA


hen you come across an extraordinary story … you want to share it with the world. We have found such a story in a Florida nursing home system that has created a special way to honor and celebrate the lives of those residents who are soon to leave our world. Their endof-life quality program is called Butterflies are Free. The following is their story, in their words. You’ll learn how the program at Life Care Center of Sarasota started and how you can provide this exceptional care to your residents and their families.


The Catalyst Imagine our horror as we read a 2002 article in The New York Times quoting physicians from the American Medical Association as saying that “nursing homes are the worst place to die.” We were distressed to read such a negative, broad, sweeping generalization about nursing homes, especially when we believe that our nursing home is an exception to the rule. We decided to prove them wrong. Yet, when we examined our care and services, we quickly realized that what we provided for the dying resident wasn’t any different from what we provided for the nondying. So, on September 17, 2002, our continuous quality improvement (CQI) project was to develop a quality end-of-life program – Butterflies are Free. The butterfly signifies moving from one life to the next. We Tapped Great Resources To get started, we began tapping into every resource we could find. The executive director attended an end-oflife seminar at the Florida Health Care Association’s annual conference. The director of nursing began meeting with our local hospice. The social worker began looking online for end-of-life resources. We found several Web sites as well as Dr. Elisabeth Kübler-Ross’ “stages of grieving” (denial, anger, bargaining, depression and acceptance) to be particularly helpful. Two Web sites we found to be helpful End-of-Life Nursing Education Consortium (ELNEC) California Coalition for Compassionate Care (CCCC) We Took an In-depth Look at Ourselves Using the CCCC’s “Assessing Your Facility’s Policy and Practice of End-of-Life,” we completed a facility selfassessment to determine how we felt about providing good end-of-life practices. We identified strengths, weaknesses and opportunities for improvement and established baseline data with which we would measure

Improving Quality of Care Based on CMS Guidelines


Instead of wondering if your clinical team is in compliance with the updated CMS Tags F309 and F314, take action with Medline’s Compass Program. This comprehensive system of educational aids, best-practice protocols and clinical tools takes the guesswork out of developing an effective skin and wound care program in your facility. The Compass Program was developed by Medline’s Wound Care Advisory Board and Clinical Team to help your clinicians meet standards of practice, improve care outcomes and be survey-ready all the time. What’s in the box? • DON Instruction Manual (like a teacher’s guide) • Survey Readiness Resource Books (put them on your treatment cart!) • Self-study education programs (staff can earn CE credit) • Wound care application videos (usage instructions for Medline’s advanced wound care products) • Wound measuring rulers (for consistent measuring) • Continuous Pressure Ulcer Prevention booklets (to improve communication and documentation)

To learn more about Compass, contact your Medline representative or call 1-800-MEDLINE.
©2006 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

our progress. We reviewed the needs of our residents, their families and our associates to determine what services were needed at the end of life. Some of the key issues identified were: • Residents and families had major concerns about comfort. • Families didn’t know what to expect from the dying process and were reluctant to accept their loved ones’ approaching deaths. • Financial strain on residents and their families were posed by end-of-life programs already operating in the community. • Our associates felt just as uncomfortable with the dying process as the families because of a lack of education and experience.

The Butterfly Process The resident is identified for end-of-life care through the Butterfly Watch process. For example, the resident could be identified through a change in two or more indicators, e.g., weight loss, pressure ulcers, falls, infections, mental status, level of function or continence status. After completion of a 14-day observation period (based on the above criteria), a determination is made for a significant change in status or admission into the program. If residents have a sudden decline in condition, they can be admitted into the program. Notification The resident and family are notified of the program and education is provided on the program’s stages and what to expect in the dying process. Hospice consult is also offered. The resident or legal decision maker provides signed consent to participate in the program.

We assembled an interdisciplinary team to set our mission and our goals, including the executive director, director of nursing, social services director, financial director, activity director and volunteer representatives from nursing, dietary and housekeeping. Three family members, representing various faiths, were also involved in the early planning stages. Our Mission Statement and Goals Were Set Mission: “To provide comfort through palliative care and individualized attention for those residents who are at or near the end of their life.” We would accomplish this by “establishing an end-of-life program that maintains comfort and dignity for the resident, involving the family, residents, and staff in the plan of care at their personal level of comfort. The end-of-life program should put no financial strain on the family.”

Placing a butterfly by a resident's nameplate identifies the resident as one who is in the Butterflies are Free program.

Improving Quality of Care Based on CMS Guidelines


Assessment Social services completes the spiritual assessment, ensuring that end-of-life wishes are known and opportunities for unresolved issues are available. Kübler-Ross’ five stages of grieving are reviewed with families to help them cope with feelings of loss. Care Plan Development An end-of-life care plan is developed with the resident and family. The three stages of the program are again reviewed with the resident and family. (Just as each resident ages differently, residents die differently, and not every stage will apply equally to each resident.) Discussions are held regarding medications, lab tests and diet and consistency of food, as well as psychosocial and spiritual needs. The care plan will change and need to be updated as the resident progresses through the dying process. A Focus Charting alert is placed in the resident’s chart so that nurses will know to chart on the areas that are highlighted. The highlighted items come from the care-planning process. A checklist is given to the nurse manager of the resident’s unit to ensure that we have not overlooked any opportunity to bring comfort to the resident.

Resident’s Room The resident’s name and stage in the program are listed on the daily bed management form. Residents are reviewed daily if changes are noted. A butterfly is placed above or below the nameplate at the door of the resident’s room to identify that the resident is in the program. A butterfly sticker is placed on the spine of the resident’s chart to alert the nurses that the resident is in the program. A butterfly night-light and Butterfly Journal are placed on the bedside table. An activity department representative will interview the resident or the family to determine a favorite hobby or travel destination that the resident has enjoyed. Every effort is made to decorate the resident’s room so that he/she will remember the hobby, activity or favorite travel destination. If desired, a Butterfly Cart is wheeled into the resident’s room. The cart is a threedrawer heavy plastic cart on rollers that can be purchased at any discount or office supply store. In the cart are items the team believes will bring comfort to the resident and the family. Daily Visits The program’s chairperson is a housekeeper who makes Butterfly rounds every day. She invites others to come along and meet the residents. Residents are invited to come and visit with other Butterfly residents, and often they do sit and hold a hand. Other times they pray together. Associates make several visits to the residents. Some associates stop to pray, others read to the residents and yet others just stop by to ensure that the residents are

The ice cream shop is open every day and all residents can receive a free dish of their favorite ice cream. The staff reports that ice cream is one of the most-requested comfort foods.



are Free
comfortable or to tell them that they are loved. Everyone writes in the resident’s journal. Music is played, if desired, and lightly scented lotion is applied to the resident’s hands and arms, if appropriate. Other attempts are also made to soothe and comfort the resident. Family Involvement Families are invited to participate in the resident’s care at their own level of comfort. For example, if a family member wants to participate in the pain-management program, training is given on how to monitor for signs and symptoms of anxiety and pain. When family members see these signs and symptoms, they will alert the nurse so that medication can be given. Moving Through the Process As the resident moves through the dying process, the care plan is constantly updated. Making changes to the texture of food is important, and comfort foods are added as desired. (Cookies and ice cream is the number one requested comfort food, and associates are quick to fill those requests.) Routine medications are normally discontinued and pain medications are monitored for effectiveness. Labs and X-rays are discontinued unless they address an acute situation, relief of which might enhance the resident’s comfort. • Dietary routinely checks with the family to see if snacks or soft drinks are needed. • Spiritual comfort is provided per the resident’s preference. • Every effort is made to have associates in the room with the resident at the time of death. • Following the resident’s death, a book called Beyond This Day, with stories and devotionals geared toward helping the family cope with the death of a loved one, is mailed to the family, along with a cedar keepsake box and the Butterfly Journal. A stuffed bear (similar to a Beanie Baby®) with a butterfly embroidered on its stomach is given to the family as a keepsake. When a family has small children, we often give each child a Butterfly Bear. • Associates attend funeral services for the deceased resident and have been asked to speak at the funerals of several residents. Memorial services are also held at the facility.
Meeting the spiritual needs of the dying resident is very important. Here, an associate is reciting the Lord's Prayer with a resident.

To learn the step-by-step details of how you can set up a Butterflies are Free program in your facility, contact Nina Willingham at We have included a sampling of the Butterflies are Free forms starting on Page 94.

Looking for more? Visit to browse the complete program and its accompanying video.

Improving Quality of Care Based on CMS Guidelines


es are Free

Nina Willingham is a Licensed and Certified Nursing Home Administrator (CNHA). She currently serves as the senior executive director of Life Care Centers of Sarasota. Under her direction, Life Care Centers of Sarasota was named to the 2003, 2004 and 2006 editions of America’s Top Nursing Homes; voted as Life Care Centers of America Facility of the Year in 2003; earned the JCAHO Ernest A. Codman Award in 2004; earned the American Health Care Association Step I Quality Award in 2004 and received Nursing Homes magazine’s 2005 Optima Award. Nina was named Nursing Home Administrator of the Year in 2006 by the Florida Health Care Association. She is also currently a member of many professional organizations, including acting chair of the Professional Development Committee of the Florida Health Care Association, member of the Ethics Committee for the American Health Care Association and Health Science Advisory Committee of Sarasota County Technical Institute, treasurer of the Florida Health Care Association, member of the Florida Health Care Association Quality Credentialing Committee and president of the Education Foundation of the Florida Health Care Association Service Corporation.

Make sure to go to to learn more on the Butterflies are Free program! Complete the form on the Web site to receive a copy of the program from Medline.




advice from a former surveyor



I have heard that surveyors have been issuing fines to nurses for things like using veterinary product on skin. I hear one nurse was fined $1,000. Is this true? Can individual nurses be fined by CMS surveyors? Amanda R., DON Dallas, Texas Dear Amanda,

accepted, adopted or promulgated by recognized professional organizations or national accrediting bodies.” Standards of practice describe the responsibilities of healthcare professionals and are based on the values, priorities and practice of a profession and describe the minimal standards of performance against which actual performance can be compared. Standards of practice also promote consistency and quality and encourage a common, systematic approach based on the most current scientific evidence. Standards of practice for pressure ulcer treatment have changed based on scientific research. In the 1980s, the use of heat lamps was common in treating pressure ulcers. However, scientific research demonstrated that moist wound healing promotes faster wound healing and is less painful. Therefore, the use of a heat lamp would not meet current standards of practice. Even if a nurse is following a physician’s order, the facility could be cited for failing to follow a standard of practice. Nurses are expected to question an order if the nurse knew or should have known that the order did not meet standards of practice or could cause harm to a resident. Ignorance is not an excuse. Nurses are expected to remain up to date with current standards of practice. In order to ensure that they follow and stay up to date with current standards of practice, nurses should subscribe to and read industry and nursing periodicals, have a copy of the nurse practice act for their state, have a copy of the regulations that relate to their practice setting and have a copy of the standards of practice for their practice setting (for example, the National Gerontological Nursing Association publishes standards of practice for gerontological nurses).

CMS state surveyors do not issue fines or sanctions against individual employees, including nurses. If a fine or sanction is issued, it is issued to the facility, not to an individual. The facility can receive a deficiency based upon the actions of an employee. For example, if a nurse did not follow infectioncontrol standards when completing a dressing change, the surveyors would issue the facility a deficiency. However, if an individual employee’s conduct or deficient practice was egregious, the surveyors could report, or require the facility to report, the individual to any appropriate licensing agencies and/or any appropriate law-enforcement agency, depending on the deficiency. In the example you have given where a nurse applied a product intended for veterinary use, the deficiency was likely issued for failing to follow standards of practice. The use of a veterinary product intended by the manufacturer for use on animals, not humans, would not meet standards of practice if the product was used on a human. The CMS Medical Director F-Tag (F501) contains the following: “Current standards of practice refers to approaches to care, procedures, techniques, treatments, etc., that are based on research and/or expert consensus and that are contained in current manuals, textbooks or publications, or that are

Molly C. Morand, RN, BSN, BC is a certified gerontological nurse and former long term care surveyor. President of the Morand Group, LLC, a healthcare consulting firm, she provides consultation to long term care facilities, hospitals, provider organizations, consumer organizations and suppliers throughout the United States on regulatory, compliance and quality of life issues. Ms. Morand has provided expert witness testimony related to pressure ulcers, skin care and incontinence care. She has been the guest of many associations and is frequently asked to share her expertise in long term care. She can be reached at 513-470-4894 or

Improving Quality of Care Based on CMS Guidelines


CMS and Psychosocial

in determining the severity of psychosocial outcomes including, for example, those outcomes involving mood and behavior, dignity and pain. For example, when evaluating incontinence care, surveyors will focus as much on privacy and dignity as they will on the actual procedure (hand washing and infection control, etc.). This guide, which became effective on June 8, 2006, specifically targets psychosocial outcomes that result from noncompliance at a specific F-Tag (in the above example, F315). The guide can be used with any F-Tag because psychosocial outcomes can result from a facility’s noncompliance with any regulatory requirement. Unlike other releases from CMS, the guide is not a regulation. Rather, it is a tool used to determine the severity of a deficiency in any regulatory grouping (e.g., Quality of Care, Quality of Life) that resulted in a negative psychosocial outcome. The guide does not replace the current scope and severity grid. It will be used in conjunction with the grid. When applying the guide, the survey team will select the level of severity for the deficiency based on the highest level of physical or psychosocial outcome. For example, “a resident who was slapped by a staff member may experience only a minor physical outcome from the slap but suffer

The Centers for Medicare and Medicaid Services recently introduced the Psychosocial Outcome Severity Guide. As its name suggests, the guide aids surveyors

By Molly Morand, RN, BSN, BC



Improving Quality of Care Based on CMS Guidelines


A resident
who was slapped by a staff member may experience only a minor physical outcome from the slap but suffer a greater psychosocial outcome.

a greater psychosocial outcome.”1 Since the severity of the psychosocial outcome of the resident being slapped was higher than the physical outcome, the psychosocial outcome would be used as the level of severity. CMS Stresses Importance of Physical and Psychological Outcomes Although some residents might experience either a negative physical or psychosocial outcome, others might experience both. With the release of the Psychosocial Outcome Severity Guide, CMS is clearly stating that physical outcomes (such as a pressure ulcer) and psychosocial outcomes (such as embarrassment) are equally important in determining the severity of noncompliance, and both will be considered before assigning a severity level. Surveyors Will Look for Connections It is important to remember that the presence of a given affect (e.g., behavioral manifestation of mood demonstrated by the resident) does not necessarily indicate a psychosocial outcome directly related to noncompliance. A resident’s reactions and responses (or lack thereof) can also be affected by preexisting issues, such as illnesses, medication side effects and other factors. Nursing home residents might experience sadness, anger, loss of self-esteem, etc. in reaction to normal life experiences, so the survey team must determine

whether the psychosocial outcome is the result of noncompliance on the part of the facility. Therefore, it is critical that facilities document if a resident has always been anxious, for example. This documentation might read, “Resident’s daughter reports that the resident has always been anxious, that previous attempts at behavioral intervention and medication have been unsuccessful and that the resident is only happy when she has something to worry about.” Surveyors are interested in psychosocial outcomes caused by the facility’s noncompliance with any regulation. This also includes psychosocial outcomes resulting from the facility’s failure to assess and develop an adequate care plan to address a resident’s preexisting psychosocial issues, which led to continuation or worsening of the condition. For example, if a resident was admitted with depression and the facility failed to assess, develop and implement an individualized plan of care, the facility could receive a deficiency. However, a resident being depressed does not mean the facility caused the depression or failed to provide necessary interventions. In order to apply the guide, the survey team must have established a connection between the noncompliance (at any regulation) and a negative psychosocial outcome as evidenced by observations, record review and/or interviews with residents, their representatives and/or staff.



Psychosocial Documentation is Critical Surveyors will evaluate each resident’s psychosocial response to the noncompliance. This will then be the basis for determining psychosocial severity of a deficiency. The surveyors will evaluate each resident’s behavior and mood before and after the noncompliance. This evaluation could include Minimum Data Set assessments, admission assessments, behavior logs, social service notes, activity progress notes and activity participation logs and physician progress notes. The survey team will determine severity based on the resident’s response in the following circumstances: • If the resident can communicate a psychosocial reaction to the deficient practice, compare this response to the guide (e.g., the resident can say they are depressed or angry); or • If the resident is unable to express her/himself verbally but shows a noticeable nonverbal response related to the deficiency. The Reasonable Person Concept This is the most controversial component of the guide. The concern is that surveyors will evaluate harm in part by whether a reasonable person (not necessarily the resident) would be upset or offended by what the facility did.

Surveyors will evaluate each resident’s psychosocial response to the noncompliance, and this will then be the basis for determining psychosocial severity of a deficiency.
cognitive impairments, physical impairments or insufficient documentation by the facility.” In this situation, the survey team may use the reasonable person concept to evaluate the severity of the deficient practice; or • “The resident’s reaction to a deficient practice is markedly incongruent with the level of reaction the reasonable person would have to the deficient practice. In this situation, the survey team may use the reasonable person concept to evaluate the potential severity of the deficient practice.” 1 For example, if a verbal, alert, oriented resident was provided personal care with the resident’s door open and the resident was visible to staff and visitors in the hallway, and the resident said they did not mind, the survey team could still cite the facility because this is incongruent with a response a reasonable person would have.

To apply the reasonable person concept, the survey team will determine the severity of the psychosocial outcome or potential outcome the deficiency might have had on a reasonable person in the resident’s position. For example, if a nonverbal resident was provided personal care with the resident’s door open and the resident was visible to staff and visitors in the hall, the survey team could apply the reasonable person concept because even though the resident cannot state that he was embarrassed or humiliated, a reasonable person would be. The survey team can use the reasonable person concept when the resident’s psychosocial outcome might not be readily determinable. For example, the reasonable person concept can be used when: • “There is no discernable response or when circumstances obstruct the direct evaluation of the resident’s psychosocial outcome. Such circumstances may include, but are not limited to, the resident’s death, subsequent injury,

Improving Quality of Care Based on CMS Guidelines


larification of C terms
In the Psychosocial Outcome Severity Guide, CMS has provided definitions for the following terms: “Anger refers to an emotion caused by the frustrated attempts to attain a goal, or in response to hostile or disturbing actions such as insults, injuries or threats that do not come from a feared source. Apathy refers to a marked indifference to the environment; lack of a response to a situation; lack of interest in or concern for things that others find moving or exciting; absence or suppression of passion, emotion or excitement. Anxiety refers to the apprehensive anticipation of future danger or misfortune accompanied by a feeling of distress, sadness or somatic symptoms of tension. Somatic symptoms of tension may include, but are not limited to, restlessness, irritability, hypervigilance, an exaggerated startle response, increased muscle tone and teeth grinding. The focus of anticipated danger may be internal or external. Dehumanization refers to the deprivation of human qualities or attributes such as individuality, compassion or civility. Dehumanization is the outcome resulting from having been treated as an inanimate object or as having no emotions, feelings or sensations. Depressed mood (which does not necessarily constitute clinical depression) is indicated by negative statements, self-deprecation, sad facial expressions, crying and tearfulness, withdrawal from activities of interest and/or reduced social interactions. Some residents such as those with moderate or severe cognitive impairment may be more likely to demonstrate nonverbal symptoms of depression. Humiliation refers to a feeling of shame due to being embarrassed, disgraced or depreciated. Some individuals lose so much self-esteem through humiliation that they become depressed.”1

Examples from Psychosocial Outcome Severity Guide Examples of how the guide will be applied, and areas that may be cited as psychosocial outcomes, are listed below. Please refer to the guide for a complete listing.

4 3

Severity Level 4 Considerations:
Immediate Jeopardy to Resident Health or Safety

• Sustained and intense crying, moaning, screaming or combative behavior. • Expressions (verbal and/or nonverbal) of severe, unrelenting, excruciating and unrelieved pain; pain has become all-consuming and overwhelms the resident. • Ongoing, persistent expression of dehumanization or humiliation in response to an identifiable situation, that persists regardless of whether the precipitating event(s) has ceased and has resulted in a potentially life-threatening consequence.

Severity Level 3 Considerations:
Actual Harm That Is Not Immediate Jeopardy

• Persistent depressed mood that may be manifested by verbal and nonverbal symptoms such as: - Social withdrawal; irritability; anxiety; hopelessness; tearfulness; crying; moaning; - Loss of interest or ability to experience or feel pleasure nearly every day for much of the day;



• Apathy and social disengagement, such as listlessness; slowness of response and thought (psychomotor retardation); lack of interest or concern, especially in matters of general importance and appeal, resulting from facility noncompliance.

2 1

Severity Level 2 Considerations:
No Actual Harm with Potential for More Than Minimal Harm that is Not Immediate Jeopardy

• Intermittent sadness, as reflected in facial expression and/or demeanor, tearfulness, crying, or verbal/vocal agitation (e.g., repeated requests for help, moaning, and sighing). • Complaints of boredom and/or reports that there is nothing to do, accompanied by expressions of periodic distress that do not result in maladaptive behaviors (e.g., verbal or physical aggression).

Putting the New Psychosocial Guide into Practice Facilities have always put a lot of focus on residents’ physical health – preventing pressure ulcers, treating incontinence, etc. However, with the release and implementation of the Psychosocial Outcome Severity Guide, CMS is clearly saying that a resident’s emotional and psychosocial health is as important as his physical health. In order to meet these requirements, avoid regulatory risk and improve the resident’s quality of life, facilities must place as much emphasis on psychosocial care as they do physical care. Facilities can do this in much the same way that they focus on and improve physical care: • Implementing reward programs where staff are rewarded for providing appropriate behavioral interventions • Including evaluation of psychosocial care in QA/QI audits and in discussions at QA/QI meetings • Providing educational programs on psychosocial care • Providing role-play opportunities related to psychosocial interventions and • Including questions regarding psychosocial care in customer satisfaction surveys

Everyone is Part of the Team CMS consistently refers to “the facility” throughout the guideline, indicating it is everyone in the facility’s responsibility to meet a resident’s psychosocial needs. This is not just a social service issue. Just like meeting residents’ physical needs requires an interdisciplinary effort, so, too, does meeting residents’ psychosocial needs. Meeting residents’ psychosocial needs and improving quality of life for all residents is not easy and will take consistent and diligent team effort – but the rewards are priceless! For a complete copy of the Psychosocial Outcome Severity Guide, visit:
Reference 1 Psychosocial Outcome Severity Guide. In: Guidance to Surveyors of Long Term Care Facilities. Department of Health and Human Services and Centers for Medicare and Medicaid Services. 2006. Molly C. Morand, RN, BSN, BC is a certified gerontological nurse and former long term care surveyor. President of the Morand Group, LLC, a healthcare consulting firm, she provides consultation to long term care facilities, hospitals, provider organizations, consumer organizations and suppliers throughout the United States on regulatory, compliance and quality-of-life issues. Ms. Morand has provided expert witness testimony related to pressure ulcers, skin care and incontinence care. She has been the guest of many associations where she is asked to share her expertise in long term care. She can be reached at 513-470-4894 or

Severity Level 1 Considerations:
No Actual Harm with Potential for Minimal Harm

Severity Level 1 is not an option because any facility practice that results in a reduction of psychosocial well-being diminishes the resident’s quality of life. The deficiency is, therefore, at least a Severity Level 2 because it has the potential for more than minimal harm.”1

Improving Quality of Care Based on CMS Guidelines



Can a Cranberry a Day Keep UTIs Away?
Is it just folk wisdom, or can this very tart berry actually be used to prevent urinary tract infections?
Early Research
As early as the turn of the century, research suggested that cranberries acidified urine, thus creating an inhospitable environment in the bladder for the bacteria that causes urinary tract infections. More recent research suggests that the cranberry could have bacteria-busting mechanisms other than lowering urine pH. Studies show positive results, but, research aside, do physicians actually order cranberry juice for therapeutic prophylaxis? Upon reviewing 176 charts, it was found that 15 residents had doctors’ orders for one cranberry tab daily for the prevention of urinary tract infections. Cranberry is available for purchase in a variety of forms. Beyond the traditional juice form, cranberry supplements can be found as extracts, teas and capsules or tablets. More information on the cranberry’s health benefits can be found at
References Avorn J, Monane M, Gurwitz JH, et al. Reduction of bacteriuria and pyuria after ingestion of cranberry juice. Journal of the American Medical Association. 1994. Howell A, Foxman B. Fewer infections may mean less antibiotic therapy. Journal of the American Medical Association. 2002.

Contemporary Research
Modern research shows that cranberries contain proanthocyanidins, which prevent the adhesion of certain bacteria, including E. coli, to the urinary tract wall. Bacteria that attach to the mucus lining of the urinary tract are more likely to contribute to infection, while unattached bacteria are simply eliminated with urination.

Clinical Observations
A small study involving sixteen children with spina bifida tracked the presence of white blood cells in the urine (markers of infection) while they consumed two to three glasses of cranberry juice daily. At the onset of the study, most of the children had measurable levels of both blood cell types in the urine. After two weeks of consuming the cranberry juice, the levels dropped.



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©2006 Medline Industries, Inc. One Medline Place, Mundelein, IL, 60060.

Healthy Skin Interview
For this issue’s Healthy Skin interview, Deb Tenge spoke with Pamela Quirk, APRN, BC, gerontological clinical nurse specialist at the Soldiers’ Home in Holyoke, Massachusetts. Established in 1952, the Soldiers’ Home provides both long term and outpatient care services to eligible veterans who reside in the state of Massachusetts.

es ri to S ss ce uc Care S ence tin
n nco ith I w
Interview by Deb Tenge



In 1999, the Soldiers’ Home created a bowel and bladder team to investigate and develop an evidence-based bowel and bladder policy and procedure. At the time, Soldiers’ Home’s incontinence budget was out of control. Incontinence products were not being used consistently on residents, which led to skin problems, leakage, odor and ultimately complaints from the residents and their families. That was then, this is now. Under Soldiers’ Home’s revamped incontinence program, residents now experience less leakage, fewer skin problems and a reduction in urinary tract infections – and the facility can also boast about cost savings. While Soldiers’ Home, being a veterans facility, is not required to follow CMS guidelines, Pamela Quirk says they elect to do so. The issues they face regarding incontinence are the same issues seen in other long term care facilities. Why not see if the changes they made at their facility could benefit yours? Q – Deb Tenge: Can you provide some background information about the facility? A – Pamela Quirk: We are accredited by the Joint Commission on Accreditation of Healthcare Organizations and are inspected annually by the Veterans Administration. Although we are not inspected by state surveyors, we do follow CMS guidelines. Services are provided to veterans who are in need of long term care and outpatient services including optometry, ophthalmology, orthopedics, dental, ENT, minor surgery, podiatry, urology, hematology, nephrology and cardiology. Q – DT: What is your total licensed census and what are the current incontinence issues for your population? A – PQ: The current census is 275 LTC beds. Included in this census are an eight-bed acute unit and 18 comfort care beds. The facility has a larger male population, with only 16 females in residence. As far as incontinence is concerned, there are more overflow incontinence issues, due to our predominately male population. We also encounter more benign prostatic hypertrophy and prostate cancer compared to other long term care facilities.

Soldiers’ Home facility

Several members of the bowel and bladder team; Lori Manning, Michelle Beaudry, Jim Sadlowski and Judy Pickford.

Improving Quality of Care Based on CMS Guidelines


Problem • Incontinence budget out of control • Inconsistent product usage on residents • Complaints from residents and families Solution • Education of staff • Assessment and proper sizing • List of residents, product used, size used

• Leakage and odors • Skin problems related to incontinence

• Spreadsheet calculates par levels for each unit so delivery is correct • Monthly quality improvement checks encourage staff compliance

Results: • Cost savings • Fewer UTIs • Dramatic reduction in leakage • Improved staff compliance • Decreased incidence of skin problems– from 4.4 percent in 2003 to 2 percent in 2006

Q – DT: When did you start your incontinence team, and why was it started? A – PQ: The bowel and bladder team officially began in response to the facility change from a more institutional organization to units we call veteran care centers. There are four veteran care centers, each managed by a veteran care coordinator. Each coordinator is a team leader for one of our focus groups targeted at one of four areas: skin, pain, falls, and bowel and bladder. I was assigned to bowel and bladder, beginning a new enthusiasm for incontinence care. Q – DT: What were the initial issues you wanted to target? Who was on your team? A – PQ: Initially, the goal was to investigate and develop an evidence-based bowel and bladder policy and procedure. My group had representation from each unit with licensed staff, CNAs, a social worker and a dietitian. We included all work shifts. In the beginning, it was difficult to get consistent representation from each of the shifts and units. This continues to be an issue, especially on the 3-11 shift, where there is a higher rate of staff turnover.

In 2005, we added the infection control nurse to comply with F-Tag 315 changes with the goal of decreasing UTIs. We also added the buyer, central supply clerk and storeroom clerk to address distribution issues. Staff members were chosen based on their interest in bowel and bladder health and also their leadership abilities and experience here at the facility.

Judy Pickford makes sure that the right-sized product is used on the right resident by checking the list.



Q – DT: What problems were you looking to solve? A – PQ: There was a variety of issues. We had complaints from veterans and their families about wet clothes and odors. The residents were not always wearing a consistent product because by the weekend all the larges were gone and the staff had to substitute something different. The perception at the time was that a bigger brief would hold more and control leakage better. Also, on the bed we often had blue underpads stacked with reusable underpads in several layers–all on top of a pressure reduction mattress, so the effectiveness of the therapy was diminished. We had skin issues due to incontinence that we felt could be avoided. Also, the staff ’s efforts to manage incontinence leakage often resulted in “brief stuffing” (placing additional products within the brief ). Q – DT: How did you get started? A – PQ: We took advantage of clinical support from our incontinence vendor in the form of a nurse specializing in incontinence. The incontinence nurse began doing education and rounds on all shifts to assist with development of our policy and procedures. She in-serviced proper measurement and product sizing so that the residents were fitted with the right size garment. The nurse also checked for proper brief application and use of appropriate products. This hands-on help got us off to a great start. The team made the decision to move to a more absorbent brief, which resulted in a cost savings for the facility. By using one brief that was more absorbent, the staff stopped using extra products inside briefs and reduced the use of blue underpads. Complaints have declined significantly. Both residents and families are happier with the betterperforming product. This product also saves money for the facility because it has refastenable tapes. These tapes allow staff to check the resident and continue to use the same brief if it is not soiled. Waste is reduced because tapes no longer rip the plastic.

Cathy Bergeron, Kathy Monahan, Pamela Quirk and Helga Simpson discuss incontinence issues at a recent meeting

Q – DT: What other improvements were you able to make? A – PQ: Our vendor’s incontinence nurse identified distribution problems. Each unit had deliveries once a week–a certain number of cases in each size. The storeroom was jammed on delivery day, but staff was often scrambling by the weekend. We might only have small sizes left because the larger sizes were used earlier in the week. No wonder there was leakage! This problem was alleviated when we developed a spreadsheet that set product par levels for the residents on each unit. The unit coordinator updates it regularly with sizing information and saves it on a network drive that can be accessed by the buyer and central supply personnel. Now the correct numbers of each size of briefs are delivered twice a week to the unit. This has been a huge improvement! Q – DT: Which issues took longer to solve? A – PQ: Even after education and training, our staff often used the wrong product, which drove up costs. This could have been related to our distribution system – the “who wears what item” information was not readily available to the CNAs. We have since placed individual product identification lists on supply carts and in the bathrooms, along with a size matrix and a troubleshooting guide. To truly exact change, we have found that a monthly review is critical. During these brief performance improvement rounds, we check to make sure that the lists are current and located in the cart and bathrooms. We also select five residents at random to audit whether they are in the proper product and proper size. Continued on page 98

Improving Quality of Care Based on CMS Guidelines


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By Alecia Cooper, RN, BS, MBA, CNOR



They’re Finally Here!
Following a lengthy five-year process, new guidelines for management of multidrug-resistant organisms (MDROs) were released by the CDC with specific recommendations designed to halt the progressive increase in incidence that began in the early ‘90s. Healthcare facilities in this application are defined as acute care hospitals, ambulatory care centers, homecare services, infusion therapy and, of importance to you, long term care facilities.

Two Tiers and Seven Control Measures
The first tier includes general recommendations for all healthcare settings, while the second tier has intensified interventions. These are recommended if endemic rates do not decrease or if there is a first case of an epidemiologically important MDRO identified in a healthcare organization. Each tier consists of the same seven control measures: • Administrative • MDRO education • Judicious antimicrobial use

What You Need to Know
The most common MDROs include MRSA, VISA, VRSA, VRE and MDR-GNB and are defined, in general, as bacteria that are resistant to one or more classes of antimicrobial agents. They are also usually resistant to all but one or two commercially available antimicrobial agents. Because they are so difficult to fight and significantly impact colonization, infection, treatment, costs and ultimately morbidity and mortality, measures have been defined to control and stop their transmission.

• Surveillance • Infection control precautions • Environmental • Decolonization

First Tier:
• Administrative engagement (including feedback on facility and patient care unit trends in MDRO infections) • Education and training of personnel, including MDRO transmission, trends and precautions,

Multidrug-resistant strains of M. tuberculosis are not addressed in this document because of the markedly different patterns of transmission and spread of the pathogen and the very different control interventions that are needed for prevention of M. tuberculosis infection.

measures and monitoring • Judicious use of antimicrobial agents • Monitoring of prevalence trends over time to determine whether additional interventions are needed • Standard precautions for all patients — assess patients for room placement, personal protective

Call to Action
MDRO control is one of the most serious problems that we are facing in health care and now there is a call to action! All healthcare delivery sites and systems have a role to play in controlling MDROs. Now is the time to work conscientiously to control MDROs. You can: • Assess the problem in your facility • Develop a plan • Assess the effectiveness of the plan • Modify as needed • Reassess

equipment (PPE) and other environmental needs • Contact precautions for patients known to be infected or colonized — gowns and gloves required (masks not routinely recommended — based upon patient assessment)

Improving Quality of Care Based on CMS Guidelines


Second Tier:
Indications for moving to second tier: • First case or outbreak of an epidemiologically important MDRO • When endemic rates of a target MDRO are not decreasing despite implementation of and correct adherence to the first-tier measures

Medline Keeps You Informed
Medline is proud to keep you up to date! We’re offering you a way to test your knowledge on appropriate personal protective equipment (PPE) for standard precautions. Simply visit and click on the “Free Education: Standard Precautions & Personal Protection” link. This will take you to a demonstration on the different fluid levels and direct you to a compe-

Example: At present, five residents in your long term care facility have been diagnosed with MRSA. Tier 1 recommendations are successfully implemented. In three months, you still have five residents with MRSA and an additional resident is diagnosed with MRSA.

tency quiz so you can gauge how you rate against others!

Medline’s Ami demonstration

Choose from among these second tier measures and add others as needed if not successful. • Additional recommendations for intensifying: — Administrative engagement/correction of system failures — Education and training of personnel/ adherence monitoring — Judicious use of antimicrobial agents — Monitoring of trends • Active surveillance cultures from patients in populations at risk at the time of admission to high-risk areas and at periodic intervals as needed to assess transmission. — Contact Precautions until surveillance cultures are known to be negative. • Grouping and assigning specific staff to the care of MDRO patients only • Enhanced environmental measures • Consult with experts on a case-by-case basis regarding use of decolonization therapy for patients or staff • If transmission continues despite full implementation of above, stop new admissions
Medline’s Ami doll

Right now, is offering a free course featuring the CDC’s Dr. John Jernigan and his webinar titled "Management of Multidrug-Resistant Organisms in Healthcare Settings.” The course includes a rebroadcast of the live webinar and an accompanying test. Successful completion of this course will earn you one continuing education contact hour!

Once you have completed our free offerings, why not enroll in other Medline continuing education courses? Enroll now and receive our Ami doll free with the purchase of any three courses! (The purchase price for three courses is $19.95.)

To read the new CDC MDRO guidelines in their entirety, go to

Centers for Disease Control and Prevention. Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006. Available at: Accessed November 28, 2006.



Continuing education at your fingertips.
Medline University offers more than 50 self-study nursing CE-credit courses including: • Pressure Ulcer Assessment and Documentation • Cleansing and Debriding Wounds • Skin Anatomy • Topical Dressing Selection • Isolation Guidelines for MDROs • Innovations in Hand Hygiene • Developing a Successful Continence Program • Standard Precautions Policy and Procedure An affordable online continuing education resource Enroll in continuing education courses you can attend at any time, from anywhere you have Web access! Visit to learn more.

Joint Commission Releases Pressure Ulcer Prevention Video
By Margaret Falconio-West

Tom Sarina, MD
Medical Director Penn North Centers for Advanced Wound Care Warren, PA

Sue Kuberski, RN, BSN, CWOCN
Certified Wound Ostomy Continence Nurse St. Mary’s Good Samaritan Hospital Centralia, IL

Holly Majewski, MS, LD, RDN
Registered Dietician St. Mary’s Good Samaritan Hospital Centralia, IL



The Joint Commission on Accreditation for Healthcare Organizations (JCAHO) is focused on patient safety. Originally established in 1910 by Ernest Codman, MD, and officially organized in 1951, the Joint Commission (as they are referred to today) focuses on the “end result” of hospitalization. Dr. Codman’s idea was to collect data and improve care based on the information gleaned from that data. \Today, more than 15,000 healthcare organizations are accredited by the Joint Commission and proudly display the Gold Seal of Approval™. This symbol tells the consumer that an organization meets performance standards related to quality and safety issues. The bottom line for the Joint Commission is that improved performance will likely lead to improved patient care. A few of the Joint Commission’s projects include the Sentinel Event Policy and National Patient Safety Goals. The Sentinel Event Policy and the Sentinel Event Alert describe certain events (such as unexpected death), investigate their causes and suggest programs and procedures to prevent the events. The National Patient Safety Goals are announced annually and encourage healthcare organizations to target patient-specific safety issues. This program, Do It Right, A Pressure Ulcer Prevention Makeover, was developed and funded in part by an unrestricted grant from Medline Industries, Inc. The program takes the acronym RIGHT and relates it to pressure ulcers. is for Risk. The first step to preventing the development of pressure ulcers is to identify those at risk and to what degree the risk is present. represents the Individual. Each patient must be addressed; there is no one program that will work for everyone.

is for Get Better. Be sure to address the factors that affect wound healing and do what can be done to improve the patient’s overall health.

is for Hydration and Nutrition. Consider that nutrition plays a key role in the prevention of pressure-related ulcers. reminds us to Teach the pearls of prevention. Focus not only on the healthcare team — teaching the patient and family about the development of pressure ulcers is sure to help with prevention.

The National Patient Safety Goals for 2007 include:

Goal 14 Prevent health care-associated pressure ulcers (decubitus ulcers) periodically reassess each 14A Assess andrisk for developing a pressure resident’s
ulcer (decubitus ulcer) and take action to address any identified risks. (Long Term Care) The Joint Commission Resources (JCR), an affiliate of the Joint Commission, develops and distributes educational programs and materials related to many issues within the Joint Commission. The JCR recently produced an educational program and video/DVD that is specific to the National Patient Safety Goal 14 – prevent health care-associated pressure ulcers.

Did you know…
That one of the Institute for Healthcare Improvement’s six new interventions in the 5 Million Lives Campaign is “prevent pressure ulcers”? To learn more about this intervention and the others, visit
For more information, please visit, click Education and then click Videos/DVDs.

Improving Quality of Care Based on CMS Guidelines


Chronic Wounds:
Collagen Might Be the Answer
You are seeing a resident with a chronic wound. This wound has eluded your treatment plan for years. It seems to go through a cycle during which it improves but does not close and usually deteriorates. Collagen could be the answer, and here’s why.
By Debashish Chakravatrhy, PhD




Harmful enzymes that destroy collagen prevent healing in chronic wounds. A collagen dressing can bind to several destructive enzymes like a magnet to iron filings, allowing the body’s own collagen to heal the chronic wound.

Improving Quality of Care Based on CMS Guidelines


Let’s take a look at the normal healing process
Normal wound healing involves three specific but overlapping steps or phases – inflammatory, proliferation and maturation. After hemostasis, the control of bleeding, the groundwork is set for the wound to move into the first, or inflammatory, phase of healing. This typically lasts two to three days and involves the macrophages and neutrophils cleaning the wound debris and eliminating bacteria. These cells have a short life span and are usually able to complete their mission in that time frame of two to three days. The wound then progresses into the second phase, or proliferation. This phase involves fibroblasts appearing in the wound about three days after injury. Their main function is to manufacture extracellular matrix (ECM) proteins, growth factors and angiogenic (new blood vessel) factors. This is part of the process called granulation. The ECM consists of collagen and elastin, among


other vital proteins. Collagen is secreted by the fibroblasts and is the most abundant protein in

humans, accounting for nearing 70 percent of all protein. It is one of the components that largely f you are seeing a fill the wound in normal healing. Elastin, another protein, provides strength and elasticity to the chronic wound in front of you, it may skin, though making up only about 3-4 percent of the skin’s protein. As this phase of healing be possible that your continues, cells migrate (epithelialization) and finally wound contraction occurs. problem wound is stuck in the inflammatory phase, The final phase of wound healing, maturation, can take many more months and where destructive enzymes is the final strengthening phase. During maturation, collagen continues to (examples follow) that should reorganize in the skin, gradually replacing the original scar tissue have long ago disappeared are with less-scarred, normal-appearing tissue. still present. Possibly destructive enzymes could include: • Elastase, which is secreted by neutrophils and is simply not useful at this stage in a wound’s life. Elastase destroys elastin. MMPs, keeping the MMPs occupied TIMPs are described as • Matrix metalloproteases in the activity of breaking down the “anti-MMPs” and must (MMPs). The MMPs are dressing material instead of the new outnumber the MMPs (concepproteases that are associated (de novo) collagen made by the tually speaking) for the wound with metal ions, and the worst fibroblasts working hard in a chalto heal normally. In a chronic of them are specific to collagen lenging environment. The enzymes wound, the MMP to TIMP ratio or fragments of collagen, are concentrated in the dressing, is in favor of these collagenmeaning that they seek out where collagen is plentiful, instead destroying enzymes, MMPs. collagen molecules and of in the tissue, where the fibrobchemically break them down. lasts are putting out the body’s own How should you handle • Elastase destroys other enzymes this problem? collagen at low concentrations. too – those that could be Denatured collagen, available in Bring fibroblasts to the wound that useful to the wound, such as some wound care products today, will produce fresh collagen and fill tissue inhibitors of matrix is processed chemically to the the wound bed. A very effective metalloproteinases (TIMPs). extent that it has lost the sophistimethod is to plant native collagen dressings that will bind with the cated triple helix structure of the



collagen building block that is so characteristic of skin collagen. It seems that this triple helix structure of collagen is particularly attractive to fibroblasts. Fibroblasts also thrive in structures in which they can spread out threedimensionally (as they would in real-life wound environment) and be themselves. In other words, they like to do the things that they should be doing, like secreting collagen and other important materials of the extracellular matrix. So, using a collagen product with a noticeable three-dimensional structure allows the fibroblasts to act as normally as they possibly can. Why native collagen-based dressings interact with the destructive elastase enzyme to the extent that they seem to do is still under investigation. Binding of a dressing material to elastase obviously reduces the concentration of the elastase in the wound bed, which means that less of the wound bed’s elastin is

destroyed. But, perhaps more importantly, elastase is known to play a role in creating the final destructive form of MMPs. Taking elastase out of play seriously reduces the potential of MMPs being freshly and efficiently created in the wound bed. Elastase is also known to destroy the beneficial TIMP enzymes that keep the MMP in check. A reduced elastase level allows the TIMP concentration to reach a level that keeps MMP activity low in the wound bed. What, then, happens to the dressing once applied to the chronic wound? It is taken apart (in a chemical sense) by the MMPs to which it was bound. The byproducts of this binding are collagen fragments, which are consumed by the fibroblasts. The fibroblasts will synthesize fresh collagen (or the body’s own de novo collagen) and secrete it out into an environment relatively free of MMPs, without whose removal the newly synthesized collagen would have been destroyed.

There is a good chance that the chronic but infection-free wound that mystified you in refusing to heal, even when you tried everything else, including addressing all other associative factors, will now proceed to healing.

Improving Quality of Care Based on CMS Guidelines


You can receive one CE contact hour by completing the crossword!

CE Crossword Puzzle

Collagen Dressings in Chronic Wounds

Objectives of Education:

After you read the article “Chronic Wounds,” complete the crossword puzzle. To receive your CE credit, you will need to go online to the Web site and click on the Healthy Skin magazine. Enter your answers online. You will need to provide your name, home address and license number (especially for nurses with Florida licenses to comply with CE Broker). Continuing education is valid through December 31, 2007. CE credit is provided through California Board of Registered Nursing and Florida Board of Nursing.

1 2 3

Understand how collagen dressings can help a chronic wound Differentiate between the phases of wound healing List two proteins that contribute to new tissue developement


Across 3 The collagen in a collagen wound dressing ____ to the destructive enzymes 5 Chronic wounds that are not infected often respond well to this type of dressing 6 If MMPs are bad enzymes, then TIMPs are _____ enzymes 8 The extracellular _____ (ECM) consists of collagen and elastin 9 An enzyme that destroys elastin 13 Fibroblasts produce fresh collagen and fill the _____ bed 14 Proliferation is the second _____ of healing 15 MMPs seek out _____ and break it down into fragments 17 Inflammatory phase typically lasts two to three ______ 18 Denatured collagen no longer has the triple ____ structure 20 Neutrophils help clean the wound but also secrete _______ which can be detrimental in a chronic wound 21 Protein that provides strength and elasticity to skin 22 Must outnumber MMPs in order for wound to heal normally 24 Main function is to manufacture proteins, growth factors and angiogenic factors 27 Type of collagen dressing that is effective in attracting MMPs 28 Epithelialization is when new _____ migrate over the surface of the healing wound 29 Bad enzymes will migrate to the plentiful collagen in a collagen ______ Down 1 How many phases in normal wound healing? 2 The first phase of healing 4 Collagen and elastin are both ______ 7 The final phase of wound healing 10 Byproducts of MMPs’ destruction of collagen dressings are collagen _____ 11 Destructive _____ in the wound may prevent normal wound healing 12 De novo 16 A wound that is not progressing 19 The most abundant protein in humans 23 Chronic wounds may be ____ in the inflammatory phase of healing 25 In the maturation phase, collagen continues to reorganize as ___ tissue 26 Adding a collagen dressing to the wound ___ neutralizes destructive enzymes by binding with them

Chronic Wound FAQs
How many people have chronic wounds? It is estimated that nearly 5 million Americans suffer from chronic wounds.1 What are the causes of chronic wounds? The majority of chronic, non-healing wounds can be linked to diabetes, immobilization, chronic edema and circulatory problems. Approximately 1.5 million people with non-healing wounds have diabetes, and another 2.5 million have pressure ulcers. Chronic wounds can also result from traumatic injury, non-healing surgical incisions or other diseases affecting the skin.1 How can a chronic wound be identified? A wound is considered chronic if it has not improved significantly in four weeks or completed the healing process in eight weeks.1
Reference 1 Center for Wound Healing & Hyperbaric Medicine. Frequently asked questions. Available at: Accessed December 18, 2006.

Improving Quality of Care Based on CMS Guidelines


Use of Ionic Silver* and Collagen+ to Reduce Bioburden and Promote Healing for Improved Quality of Life in a Complex Patient
Study # LIT467
ABSTRACT Statement of Problem: Provide optimal standard of care based on best practice to improve patient outcomes, by removing necrotic tissue, addressing infection, social and emotional problems and preventing patient from further surgical intervention. Rationale: Co-morbidities such as SCI/neuromuscular problems, nutritional, social and emotional to name a few are things that can significantly change the outcomes of a patient. We present a young SCI patient with paraplegia, S/P MVA in1985, with surgical repair of a Stage IV pressure ulcer in 1989. Admitted July 4, 2005 with Stage IV, necrotic, foul smell, extensively infected pressure ulcer covering the entire sacral, right trochanteric, perianal and vaginal vault area as well as bilateral foot ulcers. Her past history is unclear, unable to determine prior treatment regimens prior to presenting to our setting. Methodology: Patient admitted with malformed buttock, anus and vaginal vault making any treatment option difficult. It was necessary to address infection, reduce bioburden, and promote healing. Patient with urinary and fecal incontinence, as well as monthly menses, added to problem with choosing an appropriate advanced wound care dressing. We will demonstrate with this case the progression towards healing by utilizing advanced wound care products that are bioavailable to cleanse, debride, reduce bioburden and maintain an optimal moist environment. Results: Able to reduce ulcer size, promote granulation tissue, prevent infection, and improve nutritional status. CASE STUDY A pleasant 46 year old female was admitted to our service with a complex medical history and several risk factors that affect her ability to heal. She was involved in a motor vehicle accident in 1985 and suffered from a SCI that resulted in decreased sensation and function below T11. She is unable to participate in any of her personal care at this time, making her dependent for all of her ADLs. She is incontinent of both bowel and bladder, wearing disposable briefs for containment and has continued with her monthly menses. Past medical history is significant for a Stage IV pressure ulcer that was surgically corrected with a muscle flap procedure. She presents with a problematic deformity of her entire perineal/perianal region and a Stage IV pressure ulcers measuring 20 cm x 15 cm. The ulcer bed is granular with approximately 30% slough and eschar. There is undermining that measures 6.5 cm in the 9:00 to 11:00 range. Although she currently has a pressure ulcer, the Braden Scale is used to help identify others areas at risk for breakdown. Her score was 10, which is indicative of a “high risk” for the development of pressure ulcers. With these category scores, she needed intensive therapy in several areas, to not only prevent other ulcers, but to help this large wound progress. Sensory Perception – 4 She really had no impairment with sensory perception and was able to participate in decision making. Moisture – 1 She was constantly moist with urine, stool, and through her menstrual cycle bloody drainage. A skin care protocol was initiated. The pH balanced skin cleanser does not contain harsh surfactants and instead utilizes a phospholipid that cleanses without stripping the skin of its natural acid protective barrier. Barrier creams containing dimethicone and several silicones were also utilized. Activity – 1 Due to the MVA and subsequent SCI with paralysis in 1985, she is wheelchair bound. Pressure redistribution is a key factor, not only with existing pressure ulcer, but prevention as well. She was evaluated and issued an appropriate support surface for both her bed and wheelchair. Mobility – 1 Considered completely immobile, she is unable to make any significant or even slight pressure changing position changes. Instituting a turning schedule while in bed helped to address the needs of mobility and pressure redistribution. Teaching her position changes while in her wheelchair proved to improve her risk score, thus reducing her risk. Nutrition – 2 In July, her albumin level was 2.1 and nutrition was a big focus. By October, with nutritional education and better choices along with supplements, her level was 3.3 and into normal range of 3.6 by December 2005. Friction and Shear – 1 With slight contractures, immobility and muscle wasting, her friction and shear score was low, again placing her at high risk. Education about transferring allowed her independence, but the knowledge she gained helped her communicate with others in her care.



Mary Webb, RN, BSN, MA, CIC San Mateo Medical Center San Mateo, CA Presented at The Symposium on Advanced Wound Care, San Antonio, TX, April 2006.

She presents with a very large Stage IV pressure ulcer involving the entire perineal/perianal area extending to the buttocks. After careful assessment the decision was made to aggressively treat this wound. A protocol was written that would not only provide an optimal moist wound healing environment, but also address debridement necessary and the bacterial bioburden. The treatment plan included wound cleansing, debridement, and the use of ionic silver hydrogel with bovine collagen particles. The ionic silver hydrogel and the collagen were mixed together and applied to the wound daily to every other day.

Sacral Wound Measurements, showing almost 95% decrease in the wounds overall dimensions in approximately eight months

RESULTS Even though the double incontinence is a daily issue, her menses a monthly issue, and the potential for bacterial bioburden are present, her wounds are improving. This case demonstrates that even under complicated circumstances with multi-factorial issues affecting her ability to heal; this wound was managed and continues to improve the quality of life for this young, unfortunate patient. CONCLUSION Even the most challenging wounds can be assessed, addressed, and treated with a little ingenuity and choosing the right treatment regime. Dressings that serve several functions, such as the ionic silver hydrogel in combination with the collagen particles, provided the best healing environment for this difficult wound. We will continue to use this product combination in our clinic as a viable option for all chronic wounds. REFERENCES Baranoski S and Ayello E. Wound treatment Options (Chapter 9) in Baranoski and Ayello. Wound Care Essentials Practice Principles. Lippincott Williams & Wilkins. 2004 Fleck C, Paustian C. The Use of Sliver Containing Dressings: The New “Silver Bullet” in Wound Management?, Extended Care Product News, July/August 2003, 22-25. Gibbins B. The Antimicrobial Benefits of Silver and the Relevance of Microlattice Technology. Ostomy wound Management. 2003: 49 (suppl): S4-S7. Olveda M and Trowsdale H. Meeting the Challenges for Wounds in Home Care with a Silver Amorphous Hydrogel and Collagen. Presented at the Clinical Symposium on Skin and Wound Care, Phoenix, AZ. 2004.

Date 7-11-05 8-31-05 10-26-05 12-28-05 3-1-06 3-22-06

Measurement (L xW) 20 x 15 10.5 x 6.2 10.5 x 4.9 8.8 x 4.4 8 x 2.5 8x2

Undermining (9:00 – 11:00) 6.5 cm 4.8 cm 3 cm 3 cm 3 cm 3 cm

Over a period of eight months, this photographic series shows the progress of a complicated sacral wound. Overall, the wound decreased 95% and helped improve the quality of life for this 46 year old paraplegic female.



*Arglaes Powder from Medline Industries, Inc. Mundelein, IL Arglaes is a registered trademark of Giltech, Ltd. +Medifil Particles from BioCore, Kansas City, KS.



Improving Quality of Care Based on CMS Guidelines


Making Sense of

Research Reports
By Carol Paustian

A sample of a new wound care product and an accompanying case study of two patients are dropped on your desk. As a clinician, you often need to make clinical decisions by evaluating scientific evidence from published research and case studies. Can a study of two individuals give you enough evidence to make a decision? Here’s a review to help you and your staff in your clinical decision-making process.



How do we evaluate studies?
The best studies are set up so the control and intervention groups are receiving the same intervention with only one variable. A case series is made of several (usually at least three) Example: Group 1 gets wet-to-dry dressings; Group 2 gets advanced wound care dressings.They must be treated with the same standard of care with one exception–the intervention. Both groups need to have the same cleansing, antibiotics if indicated, compression, etc. It is improper to have Group 1 get no wound cleansing with wet-to-dry dressings while Group 2 is cleansed with wound cleanser and dressed with a mixture of silver-containing powder and collagen. Only one variable can be introduced at a time. case studies grouped together. A control group will receive standard care without any intervention. This is the “compare to” group. Crossover refers to a part of the study where the groups actually change unknowingly; the control group becomes the study group and vice versa. Double blind refers to a study where there are at least two groups (control and interventional) in which neither the subject nor the investigator knows which treatment is being administered to which group.The purpose of a double-blind The gold standard for pharmaceutical studies is a Level 1 or randomized control trial (RCT). It is not typical to find a well-constructed Level 1 study on devices such as wound dressings.They must, however, demonstrate to the FDA that the product is substantially equivalent in terms of safety and effectiveness to an already legally marketed device. For example, in the early 1980s, a revolutionary product for wound care,Vigilon®, was brought to market and went through the FDA process as a sheet hydrogel. More importantly, it became one of the standards for all other sheet hydrogels to come to market. Once a product has developed a history of safe use, the FDA may no longer require a new product to undergo formal FDA review prior to marketing. An example of this is the amorphous hydrogel category. The FDA now requires a review process only if there is another claim added to the product, such as antimicrobial silver in the hydrogel. Randomized controlled trials (RCTs) are recognized for achieving as much control as possible of confounding variables that might influence results. In wound care, it is very difficult to obtain an accurate RCT. Patients have dissimilar co-morbidities affecting circulation, nutrition and immune function, or wounds might be at different phases of healing. Clinicians need to consider other types of research in the absence of RCTs. Many healthcare providers have been trained to expect Level 1 RCTs. Realistically, it is very difficult to do these for all interventions needing to be studied. Large case series can be very powerful in predicting outcomes. Small RCTs with low numbers can be combined via meta-analysis (such as from the Cochrane Library in England) to provide excellent predictive value. Randomization means that the study groups are decided by a random method. A computer program usually does this. It might appear to the non-statistician that there is no logic to the order, but there is a method used to put the groups together with the goal of their being similar in age, sex and other co-factors. A placebo is an inactive substance often used in pharmaceutical studies. One group will receive the test medication and the other will receive a non-medicated “drug” that looks and possibly smells similar. study is to eliminate the risk of prejudice, which could distort the results. An intervention group (or study group) will receive standard care in addition to the study intervention. Case report (commonly called case study). This is a clinician’s report of 1 or 2 patients and how they responded to the intervention.

What to do?
Look at how clinical research studies are set up. Anyone, including nurses, MDs and PhD researchers, can set up an inaccurate or useless study. Does the intent of the study fall in line with the information you are looking to acquire? Be aware of the types of studies and know their advantages and disadvantages. Research studies might look complicated, but knowledge of the terminology and study setup will put you in the best position for reading and understanding research. The definitions here should get you off to a good start.

Improving Quality of Care Based on CMS Guidelines


Statistical significance means that the difference in outcome is most surely related to the fact that one group received (or did not receive) the intervention. This usually is demonstrated by a p value of <.05. In other words, it is more than 95 percent probable that the effect of the intervention was significant and can thus be labeled as statistically significant. Not obtaining statistical significance means that it is unclear that the outcome was really related to the intervention. N refers to the total number of patients or subjects in the study. The study is more powerful with larger numbers, especially if the treatment effect is likely to be small. So, the studies with a larger N are probably going to be more accurate and achieve significance. Power analysis is the determination of sample size, a pre-study calculation performed for the purpose of estimating the sample size needed to adequately test the difference between two or more therapies and establish if one is superior to the other. Hawthorne effect. When clinicians involved in a patient’s care are aware of whether the patient is receiving the study intervention or standard care, they tend to give more attention to the patient and spend more time assessing the part of the body involved in the study. This can skew the results of the study, usually making both the study and standard care groups have altered outcomes. Peer-reviewed study. This means that prior to publication of a study, experienced, knowledgeable clinicians look over the work to assess whether it is suitable and accurate for publication. When a study is not peer reviewed, an author could report misleading outcomes. Clinical practice guidelines are a way to group together all the published research reports and then assign a level of evidence.These guidelines are not rule books.They are more like cookbooks for thinking cooks. The guidelines typically include all types of evidence, including posters, case series and randomized controlled trials.

Current criteria for levels of evidence
Level 1: Randomized controlled trial that demonstrates statistically significant difference in at least one outcome Level 2: Randomized controlled trial that does not meet Level 1 criteria Level 3: Non-randomized trials with coexisting controls selected by some systematic method Level 4: Before-and-after study or case series of at least 10 patients with historical controls or controls drawn from other studies Level 5: Case series of at least 10 patients without controls Level 6: Case report of fewer than 10 patients

Carol Paustian, BSN, RN, ET/CWOCN, DAPWCA is a certified wound, ostomy and continence nurse. She has worked as a staff nurse, charge nurse and CWOCN nurse consultant in a variety of settings. Carol is a member of the Wound, Ostomy and Continence Nurses Society, Association for the Advancement of Wound Care and a diplomat in the American Professional Wound Care Association. She has lectured extensively on the areas of wound, ostomy and continence management and has published in several peer-reviewed professional journals.

References Bergstrom N, Bennet MA, Carlson CE, et al. Treatment of Pressure Ulcers: Clinical Guideline Number 15. AHCPR Publication No. 950652. Rockville, MD: Agency of Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. December 1994. Geronemus RG and Robins P. The effect of two new dressings on epidermal wound healing. J. Dermatol. Surg. Oncol. 1982;8(10):850-852. Mulrow C, Cook D (eds). Systematic reviews: Synthesis of best evidence for health care decisions. Philadelphia, PA: American College of Physicians; 1998.



How Good Are You at Assessing Risk?
Sharpen your skills with the Braden Scale.


Risk assessment tools can help you identify those at risk of developing pressure ulcers and improve their care. These risk assessments, such as the Braden Scale for Predicting Pressure Sore Risk, are composed of subscales to help identify areas of greatest risk. Patients are scored on the subscales, which include mobility, moisture, nutrition, friction/shear, sensory perception and activity. Understanding pressure ulcer risk factors will help you identify the risk before a pressure ulcer develops and help you formulate a care plan that includes prevention interventions.

Test your skills Read the following patient profile, then complete your assessment using the Braden Scale worksheet on the facing page. (Note: the answer sheet and rationale of this exercise are on page 48.)

Patient Profile Before arriving at your facility yesterday, Mabel had been living alone, cared for by her daughter for the last 15 years. She depends on assistance with all her ADLs. Up until now, Mabel has been alone at night and has not posed a safety risk to herself. With her Alzheimer’s progressing and “sundowner syndrome” increasing, Mabel is requiring more care and supervision, which is why she has entered your facility. Mabel is a breast cancer survivor, recently finishing her second round of chemotherapy following a bilateral mastectomy. She walks slowly and deliberately with a walker. Once in bed, however, she has significant upper body weakness and is unable to reposition herself. Mabel eats 100 percent of three meals per day, but requires significant prompting and often hands-on assistance. She has been about five pounds under her ideal body weight for the last 15 years. Her daughter has encouraged 32 ounces of fluid throughout the day in addition to the fluid given with her meals. Mabel is not on any fluid restriction. She drinks this additional fluid with much prompting. Her skin is warm and dry and appears well hydrated, with minimal dry skin. She takes a multiple vitamin with minerals, Darvocet N-100 PRN pain and Levoxyl 100 mcg per day. Her vital signs are within normal limits. She is alert, but confused as to the time, date and place. Mabel’s past memory recall is fair. While at home, her daughter toileted her in advance of need, therefore she remained dry during the day. Mabel is incontinent of urine and stool at night and wears a brief liner and mesh pants. If it wasn’t for the prompted voiding, Mabel would be incontinent of both urine and stool.

Her hematocrit is 44 percent, hemoglobin is16 g/dL, and albumin is 4.1 g/dL.



Complete your evaluation of the sample resident using the form below, then turn to page 48 to check your responses.

Improving Quality of Care Based on CMS Guidelines


Braden Scale for Predicting Pressure Sore Risk
Sensory Perception Moisture Activity Mobility Nutrition Friction and Shear Total Braden Scale =2 =1 =3 =2 =2 =2 Very limited Constantly moist Needs assistance Very limited Adequate Potential problem

=12, Level of Risk = High Risk

Prevention: Mabel currently has no wound or skin issues. Physical therapy/occupational therapy should be consulted to evaluate her upper body strength, endurance and ambulatory skills. She should be in a feeding program, which provides for maximal prompting and assistance, when necessary. A registered dietitian should evaluate Mabel for between-meal snacks or nutritional supplements to encourage weight gain. Mabel might be an ideal candidate for a bowel and bladder program, but she must be thoroughly evaluated. Due to her cognitive function, it could be determined that therapy will be of no benefit based on her medical diagnosis. Enroll her in therapeutic activities, such as cards, crafts and music, depending upon her ability. She should be placed on an appropriate support surface, such as a pressure reduction mattress replacement. When lying supine, elevate heels of bed with pillows (placed under calves). In the next issue of Healthy Skin, we’ll look at the Norton Plus Scale.

CLIA Waived

On Board QC

No Refrigeration

Small Sample

Why More Professionals are Choosing the INRatio PT/INR Monitoring System
For consistent PT/INR results in less than 2 minutes using one drop of fresh whole blood from a fingerstick.
Order Information: P-T100004Z INRatio Monitor Pro Kit P-T100139Z Test Strips 48/Box P-T0200235 Blood Collection Tubes 50/pk P-T200046 Printer To order: 1-800-MEDLINE (1-800-633-5463)

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• Make immediate warfarin dose changes • Allows for more frequent testing



Remember when your grandmother used to tell you

It still is...
Medline Compass programs provide clinical direction for: • Wound care and prevention • Incontinence care • Diabetes care Having comprehensive programs in place when surveyors walk in the facility might be the ounce of prevention you need. Compass can help you be survey-ready for CMS tags F309, F314 and F315. The Compass programs are practical, hands-on resources developed by Medline’s clinical staff to help your clinicians meet standards of practice, improve care outcomes and reduce regulatory risk. Compass Survey Readiness Tag F309/F314 focuses on the care and prevention of pressure and non-pressure related wounds. It offers clarification of surveyor guidelines along with clinical tools and protocols. Compass Survey Readiness Tag F315 is a comprehensive program for incontinence management, including assessment and treatment options, detailed clinical information and educational materials. Compass Diabetes Resource for Long-Term Care—with 26 percent of nursing home residents battling diabetes and its complications, this Compass program provides educational tools for residents, their families and caregivers.


©2006 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Mundelein, IL 60060




Managing DementiaRelated Incontinence
By Amin Setoodeh, BSN, RN
Approximately 46 percent of all nursing home residents and 50 percent of all residents in assisted-living facilities have some form of dementia. A resident with dementia typically experiences a decline in cognitive abilities, loss of memory, disorientation, poor judgment and changes in personality. Prevalent among elderly with dementia is the loss of bowel and bladder control, resulting in incontinence.

Common causes of incontinence include inability to recognize the urge to void, inability to hold the urge until reaching the bathroom, not being able to find the bathroom, medications, urinary tract infections or constipation. Incontinence can also develop when the individual is in an unfamiliar environment or when the individual is experiencing depression or anxiety. It is imperative for the care provider to develop a strategy to promote continence.

Improving Quality of Care Based on CMS Guidelines


Managing Dementia-Related Incontinence continued
What interventions should be considered?
The following should be considered when developing an efficient nursing care plan for individuals experiencing incontinence and dementia: • Conduct a complete physical examination to rule out underlying conditions such as urinary tract infection, vaginitis, constipation or prostate trouble. • Identify the cause and type of incontinence. • Work with the family to select clothing the • Identify the voiding pattern by noting frequency, amount and time of leakage. • Apply behavioral interventions such as promoted voiding, scheduled toileting or bladder training to promote normal bladder function. • Use disposable absorbent products in conjunction with other treatment options to promote dignity. • Use protective creams and barriers to promote good skin integrity and prevent skin breakdown. • Provide family and caregiver education. • Evaluate outcome and revise as needed. resident can easily fasten and unfasten. For example, try fabric fasteners instead of buttons. • Protective underwear might be a better choice than adult briefs since protective underwear more closely resembles the resident’s own underpants. • Ask or remind the individual to use the toilet at regular intervals. • Ensure the environment is safe by providing proper lighting, a clear path to the bathroom, walking aids and raised toilet seats, if necessary. • Make sure the environment is familiar by posting a picture of the bathroom on the bathroom door, reminding the individual where the bathroom is located or keeping the bathroom door open at all times.

Promote communication and dignity
Incontinence often has a major psychological impact on residents, resulting in anxiety for them and a more complicated care process for clinicians. Some individuals might feel depressed and have difficulty expressing emotions or communicating with others. Care providers need to ensure proper communication while protecting individuals’ dignity. Consider the following: • Respect the need for privacy as much as possible. • Remember that toileting accidents are embarrassing. • Encourage individuals to tell you when they need to use the toilet. • Pay attention to nonverbal cues, such as restlessness or hiding behind furniture. • Identify phrases for needing to use the toilet. • Do not make individuals feel guilty by

How can incontinence episodes be reduced?
Management of incontinence for individuals with dementia is a challenging task for healthcare providers, but there are ways to reduce the number of episodes of incontinence and improve patient dignity. • Consider existing medical conditions such as stroke, diabetes or physical disabilities that prevent the individuals from toileting themselves properly. • Review current medications and identify those that could increase urine output or relax the bladder, such as diuretics, sleeping pills and anti-anxiety drugs. • Eliminate bladder irritants such as cola, coffee and alcohol from the resident’s diet. • Promote proper hydration by encouraging the individual to drink six to eight glasses of water a day (unless contraindicated).

providing negative feedback or scolding them.

1. Assessment and Management of Urinary or Fecal Incontinence. Available at: Accessed November 21, 2006.



Instead of wondering if your clinical team is in compliance with the updated CMS Tag F315, take action with Medline’s Compass program. This comprehensive system of educational aids, best-practice protocols and clinical tools takes the guesswork out of developing an effective incontinence program in your facility. The Compass Program was developed by Medline’s clinical staff to help your clinicians meet standards of practice, improve care outcomes and be survey-ready at all times. What’s in the box? • DON Instruction Manual (like a teacher’s guide) • Survey Readiness Resource Books (put them on your treatment cart!) • DVD education program (staff can earn CE credit) • Forms for incontinence assessment (based on F315) • Measuring tapes (to determine absorbent product size) • Continuous Pressure Ulcer Prevention booklets (to improve communication and documentation)

To learn more about Compass, contact your Medline representative or call 1-800-MEDLINE.
©2006 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

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To learn more about Aloetouch Premoistened Wipes, contact your Medline representative or call 1-800-MEDLINE ©2006 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.


A concept of the past.
It’s been confusing. Support surface literature, product brochures and journal articles have thrown a lot of terms around. “Pressure relief” and “pressure reduction” have meant a lot of things but have been used most recently to represent a difference between a therapeutic support surface and a preventive surface. Many clinicians have been waiting for more precise definitions describing support surfaces. Wait no longer! The National Pressure Ulcer Advisory Panel (NPUAP) released the final version of support surface terms and definitions in August of 2006 as part of their Support Surface Standards Initiative. This document breaks down the terms closely associated with pressure, skin and support surfaces. With so many myths and misconceptions out there, even these experts took several years to agree on terminology. The most important thing for you to remember is that there is a new phrase to replace pressure reduction and pressure relief: pressure redistribution. We all know that the term pressure is defined as “the force exerted over an area.” To reduce pressure, you can spread the pressure over a larger area or move the pressure completely to another part of the body. In describing the way to spread pressure, the NPUAP introduces some terms that might be new to some: immersion (sinking into a surface) and envelopment (conformability of the surface to the body). Other common terms such as shear, friction and mechanical load are defined as well. In addition, there are sections that define the different types of support surfaces, the components of surfaces and the features they exhibit. The NPUAP gives clinicians a common language for discussion and description of pressure ulcer prevention and the support surfaces used. The document also includes more than 60 references that you can turn to for more information. You can download a copy of Terms and Definitions Related to Support Surfaces at

Jackie Young, RN, CWCN, DAPWCA Jackie Young is board-certified as a CWCN. She is a member of the Wound, Ostomy and Continence Nurses Society, the Association for the Advancement of Wound Care and serves as treasurer of the Southeast Region of the American Professional Wound Care Association. Jackie serves on the National Pressure Ulcer Advisory Panel (NPUAP) subcommittee for Support Surface Standards Initiative (S3I) as a Corporate Advisory Council Member.

Improving Quality of Care Based on CMS Guidelines







Foams have a valuable place in the wound care formulary because they increase dressing wear time on moderate to heavily draining wounds and extend the life of the primary dressing.
Foam dressings are a mainstay in the practitioner’s “wound care basket,” but they are frequently misused or neglected as an option because of a lack of understanding.We’re putting a “spotlight” on foam dressings to clear up confusion and provide strategies for appropriate use of foams. Foam dressings are usually prepared from polyurethane-based materials. Depending on the manufacturing process and specific chemistry chosen to prepare the polyurethane foam, the following characteristics will vary: • Hydrophilicity (the ability to absorb water and not release it under pressure) • Cell structure (with more openness in the structure being related to quicker water absorption) • Conformability • Dry and wet softness In wound healing applications, the objective is to create foam that can absorb exudate reasonably fast and retain that fluid in the foam under a reasonable degree of pressure.Think of it like a dry kitchen sponge.When dry foam is placed in the wet wound, it absorbs the fluid, just like the kitchen sponge absorbs spills on a wet counter. Understanding best practice use of foam dressings requires a brief overview of the principles of wound healing.

Improving Quality of Care Based on CMS Guidelines


A foam without adhesive is a good choice for weepy venous statis ulcers with fragile periwound skin.

Wound Healing Principles
Is the wound healing? If the answer is yes, then proceed with best practice principles, including providing an optimal moist wound environment. If, however, the answer is no, consider other factors that affect wound healing. Address issues of moisture, nutrition, mobility, pressure, friction and shear. What is the etiology of the wound? Is a biopsy necessary to rule out other disease entities? Determine if the reason for the delay is related to bioburden – is there too much bacteria, is the wound infected? Reevaluate the chosen topical treatment – is the treatment or dressing actually causing harm? Optimal Moisture - Is the wound wet or dry? If the wound is wet or there is drainage, it must be contained. Applying an absorbing product or one that addresses the drainage should be a focus. If the wound bed is dry, a product that donates moisture to the wound bed might be necessary. Research has

demonstrated that wounds heal better, faster, with less scarring and less pain in a moist environment. Remember, the overall goal is to provide an optimal environment. Tissue Condition - Is the wound viable or necrotic? If the wound is viable (living), measures should be taken to maintain the living tissue. If the wound bed is covered with necrotic (dead) tissue, slough or eschar, debridement is in order. Be sure to assess whether debridement is consistent with the overall goals for the resident.There are several methods of debriding a wound.The method used should depend on what is best for the resident. Dead Space - Does the wound have depth? If the wound has depth or dead space, loosely filling the wound cavity is necessary to allow closure by secondary intention, or “from the bottom up.” If the wound is superficial or “flat,” a cover dressing is usually acceptable.

Periwound Protection - What is the condition of the periwound skin? If the skin around the wound is compromised, denuded or raw, the secondary or anchoring dressing choice will be affected. Consider products that are non-adherent and will not stick to fragile periwound skin. If the periwound skin is not compromised, an adhesive dressing can be considered. Why the review? Each dressing type has its place in wound care. Following the principles of wound healing helps the clinician know when and how to use them to their full advantage.

How Can Foams Be Used?
Use for absorbing drainage Foams, by design, are indicated for wounds with moderate to heavy drainage. Foams can be used as a primary dressing directly on the wound surface or as a secondary dressing to provide extra absorption. Foams come in many different shapes, from squares to sacral shapes, with



Remember that hydrocolloids only manage
up to moderate drainage and are best on flat wounds. It is important to note that hydrocolloids should not be changed more than three times per week.These products are highly adhesive and require diligent care upon application and removal to avoid epidermal stripping.As an alternative, foams have many advantages: they don’t break down in the wound bed, they can hold considerably more drainage than hydrocolloids and they can be atraumatic to the surrounding tissue.

adhesives and without. Some adhesives totally coat the facing of the foam, others have only adhesive borders. Some foams are “naked” on both sides, meaning there is no top or bottom. These foams can be cut into strips and inserted into tunnels or cut to fill a cavity. Use on wounds with depth If a wound has depth, the cavity must be filled.An ideal packing material for a moderate to heavily draining wound could be an alginate to fill the “dead space” and provide absorbency.The wound can then be covered with foam as secondary dressing. Using traditional gauze or an ABD pad as secondary dressing might require a daily dressing change because of drainage. Using foam can give extended wear time for better utilization of product, cost control and, most importantly, better wound healing. Use under compression Many foams work under compression, which seems contradictory. (Note: Check with the manufacturer of the

foam before using under compression.) An example of foam use under compression is treatment of a venous stasis ulcer.The foam absorbs the wound drainage, allowing less frequent changes of the compression dressing.

either feature silver coating on the face of the foam or silver throughout the foam.

Foams Continue to Evolve
Many of the newer, more advanced foams have a silicone facing on the side that goes toward the wound. Resident pain is reduced because there is no trauma to the wound bed or to the periwound skin. One innovative silicone-faced foam also includes new polymer technology within the foam.As the exudate moves into the foam, the fluid is drawn and locked into polymer. Even under compression, there is no exudate movement back into the wound bed. Another recent technological advance is foam that contains silver to kill bacteria. Because all wounds are considered contaminated, an antimicrobial dressing might be indicated.Antimicrobial foams

Joyce Norman has vast clinical experience in many healthcare arenas, including acute care and home care. She is a member of the Wound, Ostomy and Continence Nurses Society and the Association of Rehabilitation Nurses Society. Joyce is also a member of the Association for the Advancement of Wound Care and a Diplomat in the American Professional Wound Care Association. Joyce has practiced the full scope of ET/WOC nursing since 1985 and has taught and lectured extensively throughout the country.

Improving Quality of Care Based on CMS Guidelines



I have a resident who has a venous stasis ulcer on her lower extremity with edema. Would an unna boot be appropriate?

Compression options
There are many different types of compression garments and systems to choose from. The two most common are: Unna Boot (Paste Boot) Delivers 35 to 45 mm Hg pressure on an ankle circumference of 18 to 25 cm An unna boot (paste boot) is a zinc – impregnated (with or without calamine) gauze wrap. It is best used if the resident is ambulatory because it becomes semi-rigid after application. When the resident ambulates, their calf muscle produces counterpressure against the unna boot, which causes venous blood to return to the heart. The compression, although initially adequate, is not sustained and will decrease to less than 10 mm Hg within 24 hours. Usually, because this wrap can be messy, it is covered with a gauze roll. If sustained compression is needed, a self-adherent wrap (such as CoFlex® or Coban™) is often added. To use: • Apply the dressing, beginning with two anchor turns just above the toes. • Make sure the resident dorsiflexes the foot (think toes to the nose). • Continue wrapping from the toes in a spiral to just below the gatch of the knee. • To provide for therapeutic compression, apply a self-adherent wrap on top of the rolled gauze.

This is a familiar question at the hotline as venous stasis ulcers are common in long term care facilities and are often quite challenging. A diagnosis of a venous stasis ulcer means adequate arterial blood is getting to the leg and foot, but the venous blood is not returning to the heart. This fluid increases the pressure in the capillaries and can cause an ulcer or prevent a scratch or small injury to the leg from healing.

Why so challenging?
Many clinicians focus on the wound itself, trying multiple treatment modalities without success. This lack of improvement is due to treating the result of the disease, not the disease itself. Research clearly shows us that we must treat the disease, which is venous hypertension. Compression is the key to healing venous stasis ulcers and is done with a compression garment of some type. If your resident has an Ankle-Brachial Index (ABI—see page 62) of 0.8 or higher, then therapeutic compression can be applied anywhere from 35 mm Hg to 45 mm Hg. Note: It is of the utmost importance that you ensure arterial perfusion is adequate before applying any form of compression.



Four-Layer Compression System Delivers 35-45 mm Hg pressure on an ankle circumference of 18-25 cm A four-layer compression system, such as FourFlex or Profore™, is a compression system and dressing all in one. There are four layers or wraps that together provide adequate sustained compression.

After healing has taken place
Once the wound is closed, it is important to get the patient in a therapeutic support stocking or garment. Remember, the disease is for life. The therapeutic support stocking or garment will prevent further ulcerations from occurring.

Do you have a wound or skin care question?
Call the Educare Hotline! Medline’s toll-free hotline is supervised by a board-certified enterostomal therapy/wound, ostomy and continence nurse. Just pick up the phone and call 1-888-701-SKIN (701-7456). We’re here to help!

To use: •The first layer, called cast padding, is used for padding and absorbency. Begin wrapping all layers just above the toes to just below the gatch of the knee. Start with two anchor turns just above the toes and wrap in a spiral fashion. •The second layer, also wrapped in a spiral fashion, is a short stretch crepe that is used to smooth down the first layer and provide added absorbency. •The third layer is a long stretch bandage, applied in a figure eight. The wrap is performed with a 50 percent stretch. •The fourth layer is a self-adherent wrap. This layer is applied in a spiral at a 50 percent overlap and 50 percent stretch. The entire compression system should be changed after 48 hours and then every five to seven days, depending on the amount of drainage.

Janet Jones is a boardcertified wound, ostomy and continence nurse. She has extensive experience in long term care and home care and has developed wound prevention and treatment programs for many national healthcare groups. She’s also ready to take your call on Medline’s Educare Hotline!

Hints for best practice
•Use an appropriate dressing (such as silicone-faced foam, antimicrobial dressings or an oil emulsion) directly over the wound to allow the drainage to pass into the dressing without the first layer sticking to the wound. •Remember that residents with venous hypertension often have very dry, flaky skin (venous dermatitis). Apply a topical emollient up to the wound margin, from just above the toes to just below the gatch of the knee, prior to applying the compression system. •A topical silver dressing used in conjunction with compression could aid healing. Venous ulcers are frequently contaminated and topical silver products are broad-spectrum antimicrobials.

Improving Quality of Care Based on CMS Guidelines


Ankle Brachial Index (ABI)
An ABI is the bedside comparison of the blood flow pressures in the lower leg and those in the upper arm. This screens residents for significant arterial flow problems to the extremities. An ABI will identify residents for whom compression would not be appropriate. This test might not be accurate for diabetics, whose vessels are often calcified, leading to a false positive. Procedure 1. Place resident in supine position five to 15 minutes before test. 2. Obtain brachial systolic pressure in each arm using a blood pressure cuff and doppler. 3. Record the highest brachial systolic pressure. 4. Place a cuff around the affected ankle. 5. Apply acoustic gel over the dorsalis pedis or posterior tibial pulse. 6. Lightly touch the doppler probe (at an approximately 45-degree angle) to the skin at either pulse location very lightly. Listen for a pulse. 7. Inflate the cuff higher than the brachial

systolic pressure. 8. Slowly deflate the cuff, listening for the return of the pulse. The point at which the arterial signal returns is recorded as the systolic ankle pressure. 9. Repeat to obtain the ankle pressure over the other pedal pulse on the affected extremity. Use the higher of the two values. To determine the ABI, divide the higher of the two ankle pressures by the higher of the two brachial pressures. If only one ankle pressure could be obtained, use it. Ankle Pressure = ABI Brachial Pressure Interpretation of Ankle-Brachial Index 0.95 - 1.3 Normal range 0.80 - 0.95 Compression is considered safe at this level <0.8 - 0.5 Indicates mild to moderate arterial disease <0.5 Severe arterial insufficiency >1.3 Abnormally high range


Dorsalis pedis pulse

Posterior tibial pulse


Brachial pulse



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Using the Best Words for You and Your Resident

On November 12, 2004, the Guidelines for Surveyors in updated F-Tags 314 and 309 was released.These tags are used in long term care and refer to various types of wounds. Specifically, Tag 314 addresses pressure ulcers and focuses on their prevention. The guideline gives new meaning to terms that are hardly new to healthcare providers – avoidable and unavoidable. As clinicians, we’ve all encountered the resident who has developed a pressure ulcer even though excellent care was provided. Consider a resident who is immobile, who might have severe contractures, decreased appetite with severe weight loss, lab values below the range needed for wound healing and fecal and urinary incontinence.This resident could also have dementia, be taking several medications or maybe even have diabetes. Nobody wants to see a pressure ulcer develop, but most clinicians would agree that this resident is at high risk of developing a pressure ulcer despite excellent preventive care. We would consider this a clinically unavoidable pressure ulcer.




The Guidelines for Surveyors F-Tag 314 clearly defines what the terms avoidable and unavoidable mean to CMS: Avoidable means that the resident developed a pressure ulcer and that the facility did not do one or more of the following to prevent it: • Evaluate the resident’s clinical condition and pressure risk factors • Define and implement interventions that are consistent with resident needs, resident goals and recognized standards of practice • Monitor and evaluate the impact of the interventions • Revise the interventions as appropriate Unavoidable means that the resident developed a pressure ulcer even though the facility did all of the following: • 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 • Revised the approaches as appropriate

As we can see, a pressure ulcer is labeled avoidable if one or more of tasks listed above was not performed. A pressure ulcer is unavoidable if all of the tasks were performed and an ulcer still developed. When assessing the risk for a pressure ulcer, look for guidance in a standard care plan. Care plans are necessary in taking care of our residents and every nurse should know how to complete one.The problem is that many nurses assess and address the needs of the resident but do not necessarily use the care plan as guidance. Care plans should be updated as needed – but often, when time is short, paperwork suffers. However, care is often judged using this paperwork – especially in a court of law. A wonderful resource is the American Medical Directors Association’s Clinical Practice Guideline: Pressure Ulcers. The first edition was published in 1996. It addresses recognition, diagnosis and treatment of pressure ulcers.Three years later, the second (or companion) document Clinical Practice Guideline: Pressure Ulcer Therapy Companion was released.The companion guideline adds monitoring as a focus.These documents are available for purchase for AMDA members. For more information, go to guidelines

themselves provide valuable information for healthcare providers treating residents who have or are at risk of developing pressure ulcers. Listed on the following page are statements from the 1999 companion guideline that can be used in a number of ways. Physicians, nurse practitioners and physician assistants can use them in progress notes when applicable. These statements can also be used by nurses when talking to family members regarding the risk factors contributing to the development of pressure ulcers. Chart the discussion that took place, who was present and the family’s response to the conversation.

This reference can be clipped out and posted conveniently for your staff.
Karen Lou Kennedy-Evans was the first Family Nurse Practitioner in Fort Wayne, Indiana. She worked at the Byron Health Center, a 500-bed long term care facility in Fort Wayne, Indiana, for 26 years. Her records in the 1980s led her to the discovery of a pattern to terminal pressure ulcers, a type of ulcer that is now named the Kennedy Terminal Ulcer. She currently lives in Tucson, Arizona and is the president of K.L. Kennedy, LLC.

Improving Quality of Care Based on CMS Guidelines


Good, Strong Documentation Physician Reference Progress Notes for Residents with Pressure Ulcers
It is important to document on the progress note and to discuss with the resident and/or family the risk factors predisposing the resident to pressure ulcers. Here are some additional suggestions from the AMDA Clinical Practice Guideline: Pressure Ulcer Therapy Companion to add to the progress note and to that discussion.

Page numbers are from AMDA Pressure Ulcer Therapy Companion 1. Complete wound closure might not be a realistic goal... (page 7) 2. The wound may improve but complete healing is not expected... (page 7,Table 2) 3. Patient has a slowly progressive or irreversible underlying medical condition... (page 7,Table 2) 4. The patient is likely to get worse or to die and the wound may worsen or at least is unlikely to improve significantly...(page 7,Table 2) 5. Patient has an end-stage or terminal condition… (page 7,Table 2) 6. The wound represents an additional body systems failure in an individual who is progressing towards death… (page 7,Table 2) 7. Patient has been losing weight and or not eating well despite appropriate nutritional interventions... (page 7,Table 2) 8. A treatment plan emphasizing basic comfort measures such as minimizing pain and odor related to the wound during the dying process... (page 7,Table 2) 9. The presence of Stage 3 or 4 ulcers, especially in combination with significant active comorbidities and medical instability (for example, systemic infection), may indicate general instability, decline or a terminal episode. (page 8) 10. Advanced directives by patient or substitute decision maker to forego artificial nutrition and hydration may influence the feasibility of wound healing. (page 6) 11. Comfort measures only will affect the aggressiveness of overall care and the options selected to manage related complications. Basic wound care measures – such as protecting the wound from contamination and trying to absorb excessive exudate – should be considered as comfort measures compatible with palliative care plans. (page 7) There are many reasons pressure ulcers develop, however, the conditions listed above may indicate an unavoidable pressure ulcer unrelated to the F-Tag 314.
Adapted by Karen Lou Kennedy-Evans, RN, CS, FNP References: Clinical Practice Guideline: Pressure Ulcers American Medical Directors Association, Columbia, MD. 1996. Clinical Practice Guidline: Pressure Ulcer Therapy Companion. American Medical Directors Association, Columbia, MD. 1999.

Improving Quality of Care Based on CMS Guidelines


Did you know research shows that long term care workers miss more days of work due to back injuries than truck drivers or even construction workers? Or that more than 10 percent of nurses leave the profession each year because of back injuries?1 If your facility doesn’t have a “minimal lift” program or if you’re interested in taking your

Aching Back
By Julie Finley, BSN, RN

Oh, Your

current program to the next level, we suggest the following must-reads: this article — a great case study on what works and why — and Safe Patient Handling

and Movement: A Practical Guide for Health Care Professionals. A tremendous
resource, this book provides detailed information on

“best practices in safe patient handling and movement, the current evidence base, and the scope of the problem. It also addresses the challenges of safe handling of special populations such as the morbidly obese.”1



When You Do the Math Go to the Source: Program Planning

month. First, they brought in the insurance representative to review the cost of injuries to the facility. Another early session addressed equipment. “We had only two lifters at the time and they always had battery issues. The committee wanted to change that!” A “show and tell” was organized to test equipment. The CNAs developed an equipment feedback form to help evaluate the facility’s needs. The team developed a list of all the equipment necessary to convert to a limited lift plan. Kim was prepared to make a capital investment in additional lifting aids. Countryside invested $24,000 in new equipment, including twice as many sit-to-stand lifts as sling lifts. daily experience with lifting different residents in a variety of situations, they were the ideal staff to develop the facility’s resident handling policy.

Many facilities focus so much on resident safety that addressing employee safety inevitably ends up at the bottom of the to-do list. Kim Kohls, an administrator, freely admits this was the case before she began a limited lift program at Countryside, an Aurora, Illinois, nursing home. When Kim heard in 2002 that OSHA might be looking at back injuries in her region, she recalled that her insurance representative had suggested that back injury prevention was an area ripe for improvement. At the time, her human resources department handled the workers’ compensation claims. Reviewing her facility’s statistics for the first time left Kim astonished. Six of her staff had been injured handling the same resident! At one time she had as many as three staff members on “light duty.” Kim admits, “I was embarrassed. Why had I not known this before? Lifting residents was the main source of injury to my employees. I decided to do something about it.”

Program Implementation: The Employees
Everyone in the facility was notified that the staff was going “lift free” on a certain date and a mandatory inservice was scheduled. The committee members were charged with training all of the direct care staff during this full one-day in-service. Kim notes, “Employees had to be educated too. There definitely was resistance. But our committee members were enthusiastic about how the program was for the good of the employees.”

Evaluate Your Residents
Once the equipment issue was addressed, the team knew they’d need to assess the lift needs of each resident. An initial review determined that approximately 30 percent of residents would need assistance. However, as the staff embraced the use of equipment and a newly developed resident assessment tool was put in place, the team soon realized that nearly 50 percent of the residents needed lift device assistance. By assessing each resident, the team was able to determine equipment criteria for each wing. Kim says, “To this day, the team still does the assessment for each resident.”

In 2003, the American Nurses Association (ANA) launched their “Handle with Care” ergonomics campaign to promote safe patient handling.
After training, a skills checklist went in each employee file and the program went into effect. The lifting committee was given the power to suspend anyone who didn’t use the equipment, even if that person was a superior. Kim insists that the authority to suspend is critical to the program’s success. “Immediate three-day suspensions gave teeth to the program. In three years, we have had nine people suspended, but never once was there a repeat violation.”

Kim chose ten nursing assistants to include in a meeting during which she laid out all the statistics and insurance data. “The CNAs were shocked and a lively conversation ensued. I just sat back and listened!” Kim asked if they would be willing to attack the problem and they were eager to respond. Working together with Kim on the project helped the staff feel important and empowered. Kim was impressed by the initiative, energy and enthusiasm of the CNAs on her committee, who began their work by meeting twice a week for a

Back It Up and Implement It
After evaluating costs, equipment and residents, the team found that developing a formal policy and training both staff and residents on its importance helped ensure success. Because the CNAs had

Improving Quality of Care Based on CMS Guidelines


Program Implementation: The Residents
The work of the committee was ready to be put into practice. Informing the families and the residents about the change was important. “We wanted to let the families know that the equipment was safe, that the staff would be fully trained and that resident and employee safety was a priority.” Kim adds, “It is an exposed and vulnerable feeling to be swinging in the breeze from a lift, so we wanted to make sure the residents were comfortable. During a resident council meeting, we asked residents if they thought they were the most difficult to transfer and we then demonstrated the equipment on those who volunteered. Everyone could see how the equipment worked!”

are more safety conscious. The culture at Countryside has become one of “safety first.” Beyond reducing costs and premiums, Kim is happy to report the complete elimination of light duty. “Light duty can be a cancer in a facility —all the other full-time employees hate it when they are working so hard while someone else is clipping fingernails!” When Kim is asked what she would have, in hindsight, done differently, she doesn’t hesitate to respond. “I didn’t order enough slings! We now have more than enough on hand; we wash them regularly and date them. Anything frayed is thrown away.” Countryside’s summary list of recommendations: • Plan on at least six weeks to implement your program from start to finish. • Set up a committee composed predominately of CNAs. • Develop criteria for the kinds of equipment you need. • Select a variety of equipment for consideration and recommendation. • Notify residents’ families about the new program. • Demonstrate the equipment to the residents. • Train the trainers so they can then train the staff. • Don’t be afraid to initiate suspension if equipment is not used. • Every year, retrain your staff as part of a skills fair.

Perhaps one of the greatest unpredicted benefits has been the administration’s new appreciation for their staff. “The CNAs are my biggest employee group — that’s where I can make the biggest impact,” Kim said. “Spending so much time with ten CNAs on this project made me see what a great untapped resource I had! Some of these team members have since been promoted to other positions, such as admissions or restorative specialist. Our minimal lift program has eliminated light duty, improved employee morale and given all caregivers an everyday mindset of safety for themselves.”

Julie Finley, BSN, RN, has 26 years of nursing experience divided among hospital, home, and physician office settings. She has functioned in both managerial and clinical roles; her clinical experience is in critical and home care. As a division director at a hospital, she was responsible for multiple divisions. She then transitioned into the practice setting, hiring physicians and managing their practices.
Reference: (1) Nelson A, ed. Safe Patient Handling and

Minimal Lift: A Win-Win for Countryside
The year before the Countryside program went into effect, workers’ compensation claims totaled $152,000. The year after the program was implemented, those costs dropped to just $1,200. After three years, there have been no significant lifting injuries. The committee (now called the Employee Safety Committee) continues to meet monthly for QA/QI and to address concerns about injuries and employee turnover. Other on-the-job injuries have virtually disappeared as well because staff members at all levels

Movement: A Practical Guide for Health Care Professionals. New York, NY: Springer
Publishing Company; 2006.

Suffering and Major Costs to Your Facility
• In 2000, the incidence rate for back injuries involving days away from work was 181.6 per 10,000 for nursing home workers (compared to 98.4 for truck drivers or 56.3 for construction workers).1 • In a 2001 study conducted by the ANA, 4,826 nurses cited “disabling back injury” as their second highest safety concern, just behind stress and overwork.1



Medline’s Safe ‘n Easy program teaches the seven key components of lifting and transfer. It provides comprehensive policy policy, procedure and assessment tools you can customize for your facility! The program will teach your staff how to properly use equipment including Medline’s Electric Elevating Lift which can help even the smallest staff member lift up to 600 lbs safely and easily. It also wheels under the beds and into the tightest spots. With its 24-volt batteries it has the power to keep going all day

Medline’s Safe ‘n Easy We’ve Got Your Back


said Morgenstern.

Does your fast-paced, often erratic schedule have you running on fumes? Do you laugh sarcastically when someone suggests that you have to “find that balance,” while wishing you really could? We hear this consistently from long term care employees nationwide and we want to help. So, we recently talked to an expert in the field, Julie Morgenstern. Does the name sound familiar? You might have seen her on national news programs, Oprah and other talk shows. The author of numerous time management and organization best sellers, Morgenstern has a formula that could really make a difference in your life. “When you’re working like this with an erratic schedule and you are trying to balance work and home life you really have to plan ahead to be prepared for sudden shifts in your schedule.

PEP talk
The whole point of your time off should be to recharge you as a human being. It shouldn’t be just to do laundry, the chores, and what amounts to basically another job – especially when you are working this hard. You’ve got to find a way to spend your time off that really recharges you. I teach a formula called PEP. The concept is to balance three different areas of your life. When you mix it up, plan ahead and spend your time focusing on these three areas it actually gives you energy,”



“PEP” focuses on finding balance between Physical Health, Escapes and People. Morgenstern’s latest book Never Check E-Mail in the Morning outlines this strategy. Following are excerpts from pages 25 through 32 of the book. Physical Health Lack of sleep and poor nutrition can be compensated for with caffeine, sugar, power bars or the pure will to concentrate; however, nothing is a substitute for genuine physical health. Sleep, exercise, a proper diet and regular checkups maintain your physical body. This is a basic, essential priority, which provides the well of energy from which you draw strength to accomplish everything else you need to do…making the commitment to your physical health will have an immediately visible effect on your productivity.

from a pro
The message is that physical health is extremely important! We should plan and make the time for it! So many of us get wrapped up in taking care of everyone else that we neglect our own needs. We must: • Plan to exercise • Plan to go to the doctor • Plan to eat well Escapes Certain activities renew us by providing relaxation, refreshment or just sheer delight. Think about the

Improving Quality of Care Based on CMS Guidelines


activities that instantly transport you to a place of pure joy. It could be reading, gardening, painting, dancing, listening to music or pampering yourself by taking a long bath or a long weekend. This element of your personal life is what defines you–what makes you YOU. These activities – the no-brainers of joy – are important to build into our every day lives. Adding something new and joyful to a crammed schedule actually has the effect of stretching the hours and days. You will suddenly feel like you have more time on your hands than ever, because you will be energized as you look forward to your time off, and renewed as you think back on how pleasant the time was. So PLAN time for those things that motivate and recharge you. • Plan to do nothing
Must Reads Morgenstern’s books are must reads that will help you get control of your schedule and your life. In addition to Never Check E-Mail In The Morning, we suggest you read her other best-selling books Organizing from the Inside Out and Time Management from the Inside Out.

know they are important to you. Staying connected to the people you care about isn’t only for them, though, it’s for you. There are people in your life who give you a sense of value, love and connection. Whether they are family, friends or people in your community, spending time with them is essential to your being. Keeping our relationships strong feeds our spirits, grounds us, reinforces our identities and brings out our best selves. Rewarding relationships at home can help us to tolerate tensions at work more easily. Again, make a plan to spend time with people that really matter to you. • Plan to have lunch with a friend • Plan to have dinner with your spouse • Plan to read to your children • Plan to really talk to your sister How to get started:

• Plan to get pampered • Plan to listen to music • Plan a short vacation People With the busyness of everyone’s lives, it’s very easy to take relationships for granted – you count on the history, the good times and the familial bonds to hold them together. Yet relationships thrive on more than good feelings and memories – actually spending quality, focused time with people lets them

Get a planner and write it down TODAY. Morgenstern suggests starting with your largest blocks of free time when you are not working. This could be your weekends, evenings – wherever the largest block of free time exists. Literally start scheduling things way in advance on your calendar. Front-load



your calendar with WHAT you’ll do and WHEN you’ll do it – always remembering to consider PEP. Sudden opportunity list With your erratic schedule, you need to be ready for the unexpected. Sometimes we find ourselves with an extra 15 to 30 minutes. Make a short list of things that really matter to you that you can accomplish in that time. Keep the list short. NO CHORES! Morgenstern explains, “Then every time you get a few minutes it’s a bonus and you don’t lose half the time wondering what to do. Something that is really wonderful and fabulous and not doing the dishes.” The list could include: • Lunch with my spouse • Go for a run • Calling an old friend Stuck at work The flipside is to have backup plans for those times that you are going to have to go into work when you hadn’t planned on it or for those times that you are stuck at work when you had planned to pick up your kids. Morgenstern says to “do as much preparation in advance so that when these moments happen, you are just able to execute.” Have several options


Organize Your Bag

Morgenstern has also tackled a problem you know well – organizing your bag. A new partnership with world-renowned planners Franklin Covey® has resulted in a new planner to help you incorporate PEP as well as the perfect bag to help you grab and go. Morgenstern shared these important tips about your organizing your purse or bag. The bag should be: • Light when empty • Roomy inside and flexible

Step 1. Get rid of the junk – movie tickets, old hand cream, old shopping lists and phone numbers with no names. Step 2. Divide contents into two piles Permanent items – includes keys, wallet, glasses, cell phone, pen and basic make up Transient items – includes shopping lists, bills and possibly a book Step 3. Obtain pouches for the permanent items. Those things stay in the same place in your bag at all times. Step 4. Decide where your transient things should be placed in your bag – and never put your permanent items there. Step 5. Begin a daily routine at the end of your day of unpacking the items you don’t need in your bag. Step 6. Keep your bag by the door so you can grab and go.

Improving Quality of Care Based on CMS Guidelines


planned well in advance so that you don’t always feel like you’re begging at the last minute. Keeping the balance Remain focused on PEP throughout your day. Remember to give yourself a break – both mentally and physically. “You may need, after a hard day at work, a few minutes to recharge yourself before you are able to give back to your family. So when you are home you are 100 percent present for your spouse or your kids,” said Morgenstern. Find ways to share the load Many a long term care employee has been accused by family or friends of being a control freak. That might be because there is no transition time built in to switch gears. Also try to remember that you don’t have to be “in control” at home the way you are at work. “Are you running your household and trying to be responsible for everything at home? Is your home set up in a way that people can help you? You can organize your space if you are a control freak, so that it makes it difficult for someone to help you. Look around your

house. Take away the obstacles to somebody helping you. Label the insides of cabinets to help your husband and kids know where things should go. Move the snacks to a lower shelf so the kids can help themselves,” Morgenstern suggests. You don’t have to be perfect “When people get very busy they tend to get very focused on the small practical day-to-day stuff. You have to put what is truly most important first. And those are those three things in PEP. It’s not whether the laundry is done. It’s OK not to be perfect. If you take care of your physical health, your escapes (recharge your spirit) and you take care of the people that matter first, you find that you suddenly have time for the other stuff. “It really gives you the energy to get the other chores done. The mistake most people make is that they spend way too much time on the ‘to do’ list before they get to the things that matter. The trouble with that is that the little stuff never goes away. It is a never-ending list and I don’t care how many ‘to dos’

you get done, there are always 700 more right behind them. You are never done, so how do you know when to stop? Now, on the other hand, sitting one-on-one with your spouse and spending an hour really listening and finding out how their day was – the return on investment for that is huge.”
Excerpts from pages 25 through 32 from Never Check E-Mail In The Morning reprinted with permission from Julie Morgenstern. ©2005 Fireside Publishers. All rights reserved



Julie Morgenstern
Author, Speaker, Consultant

Julie Morgenstern is an internationally renowned organizing and time management expert, best-selling author, corporate productivity consultant and speaker. Her “Inside Out” philosophy ensures customized solutions for individuals and companies, that are innovative, practical, and easy to maintain. Since 1989, Julie and her staff have worked with clients such as American Express, Microsoft, FedEx, Bear Sterns, GlaxoSmithKline, the Miami Heat, NBC-Newsroom, NYC Mayor’s Office, Sony Music, Medicare/Medicaid, Viacom/MTV and Victoria’s Secret As a speaker, media expert and corporate spokesperson, Julie is known for her engaging, articulate style and warm sense of humor. She is a columnist for O, The Oprah Magazine, solving readers’ problems by creating order in their life. Julie has been a guest on many TV and radio shows, including The Oprah Winfrey Show, The Today Show, Good Morning America, and National Public Radio programming. She is quoted and featured regularly in a wide variety of publications and has been seen in The New York Times,

The Chicago Tribune, Woman’s Day, Fitness Magazine, Cosmopolitan, and Bottom Line Business. Julie is the author of the New York Times’ best-seller ORGANIZING FROM THE INSIDE OUT and TIME MANAGEMENT FROM THE INSIDE OUT, both of which have been made into popular one-hour PBS specials. Julie and her teenage daughter Jessi co-authored ORGANIZING FROM THE INSIDE OUT FOR TEENS. Her latest book, MAKING WORK, WORK, is now available in paperback, newly titled NEVER CHECK E-MAIL IN THE MORNING.

Improving Quality of Care Based on CMS Guidelines


Julie Morgenstern Organizing System—Time Management Your Way
Julie Morgenstern shows you how to design a balanced life based on your unique personality and goals. The system’s unique page design helps you master five basic time management skills to create meaningful and fulfilling days: How to Estimate Tasks, Lighten Your Workload with the 4 Ds, Group Similar Tasks, Create a Time Map, and Control the Nibblers. Its sleek profile provides the best of mobile paper planning without the bulk. Includes one wire-bound book featuring a full year of calendars in a two-pages-per-month format and Julie Morgenstern’s Skill Building Lessons, 12 monthly Planning Books in two-pages-per-day format, a notebook, 20 Time Maps, a Pouch Pagefinder to hold the Time Map and a Month Pagefinder.

Buckle Down Leather Wire-bound Cover
Slip the Julie Morgenstern Organizer into this smooth leather cover with buckle and you’re ready to conquer your day with panache. Coordinates with the Grab & Go Bag to create a complete planning system. Features vertical pockets for important papers and a horizontal pocket for a notepad. Snap closure.

The Grab & Go Bag
This stylish tote is fun, fast and ready to go anywhere you do – from work to the soccer field to a shopping getaway. Its roomy interior fits everything from business papers to workout wear. Features two side pockets for water bottles, an umbrella or a cell phone. Large external pocket is perfect for reading material.

The Switchables Four-piece Leather Accessory Pack
This set of soft, full-grain leather pouches is designed to organize the interior of your tote and make it easy to switch bags in an instant. Includes a money pouch to hold credit cards and currency; a storage pouch for makeup, personal, electronic, or other items; a business card holder with two compartments, one for cards you give and another for cards you get and an envelope to organize receipts and small paper items. Available in red, black, and chocolate.
For more information, or to purchase the products listed, please call 1-800-680-1812 or visit your local FranklinCovey store.



What’s in a

Chiropractors Dr. Bender Dr. Popwell Gastroenterologists Dr. Butt Dr. Heine Dermatologists Dr. Spot Dr. Whitehead Internists Dr. B. Sick Pain Management Dr. Ow Dr. Pain Podiatrists Dr. Korn Dr. Smellsey Psychiatrists Dr. Looney Dr. Moodie Dr. Strange Surgeons Dr. Butcher Dr. Doctor Dr. Organ Urologists Dr. Weiner Dr. Streem

Have you ever known people who seem to be born into their profession – maybe it was their personality or even their name? Believe it or not, – these are the names of licensed physicians.



Improving Quality of Care Based on CMS Guidelines


Time Stealers
Experts say the first step in improving our time management process is identifying our biggest time stealers and working to ELIMINATE or DELEGATE them. Do any of the following get in your way?

Time Management Ellis Tips By Lynne

Time management. Sounds like an oxymoron doesn’t it? There is never really enough of it and aren’t we all too busy to manage it. How does anyone manage rushing to get the kids going, grab some coffee, wash the dishes, throw in a load of laundry, get dressed, out the door and to the hospital by 6 a.m. Yikes — how could anyone be an OR nurse and still have a life? So how about some time management tips to help get you going? After all, for busy women like you, time management is as critical as that first cup of coffee.
Eliminate and Delegate Potential Time Thiefs • Interruptions • Meetings • Lack of organization • Procrastination • Funny emails I love them but they tear me away from the important things. The way we deal with others can also have a big impact on our ability to get things done. For instance, some of us have trouble saying “no.” Some of us don’t like to delegate so we wind up doing everything ourselves.

#1. Time Waster — Failure to prioritize and plan
It takes time, but people who do it actually accomplish the most in a day. This process includes doing a little research before we jump into something. In the long run, a full understanding of the issues saves time—even if it takes more time upfront.

Let’s Make a Plan
Now that we know how important it is to clearly define our objectives and create a plan of action, we can get started by evaluating how we currently use our time. If you’re spending too much time on nonessential tasks and doing big projects at the last possible minute, planning and prioritizing will really help you get more done. Remember Too Much on Your Plate…Eliminate and Delegate!

A rule of thumb is to delegate anything that someone else could do 80% as well as you could do it.


1. 2. 3. 4. 5. 6. 7.
Plan your day Eliminate and Delegate as many time thiefs as possible Break large tasks into smaller ones so they’re not so daunting Use the 10-minute rule—spend just 10 minutes a day on dreaded tasks (a suggestion from the Mayo Clinic) Set aside a block of time each day for paperwork and emails Close your door and find other ways to eliminate distractions When possible, say “no” to extra tasks and interruptions that don’t help you reach your goals Clear your workspace of clutter—a messy desk is not the sign of a genius at work Improve your concentration by getting enough sleep and exercise Take a break when you need one – this helps eliminate stress and makes you more productive in the long run

Be sure to ask yourself if what you’re doing right now is helping you achieve your goals.




Lynne Ellis is a freelance writer from Chicago, Illinois who has written for Medline, Unted Airlines and American Airlines.

Improving Quality of Care Based on CMS Guidelines



Healthy Skin Word Search
Find 20 of the key words from this issue of Healthy Skin in the puzzle below! The words can be found up, down, backwards and diagonally in the puzzle and will occasionally share letters. Stumped? The solution is on pg. 98

Words to find:




Functional Incontinence 84

Incontinence Quality 86 Improvement/Quality Assurance and Assessment Policy & Procedure Guidelines for Use of Overnight Brief Try Our Web Tools Butterfly Watch End of Life Plan 88 90

92 94 95

This section of Healthy Skin is all about making it easier for you to do your job. It contains practical information and ideas to help you provide the best possible care for your residents while following current guidelines and standards of practice. The charts, forms and systems you'll find here are intended to be used. If you see something you like, feel free to tear it out and make it your own!

Improving Quality of Care Based on CMS Guidelines



Residents with functional incontinence have properly functioning bladders, but are incontinent for external reasons.These can include, for example, restraints, vision problems and residents who cannot transfer themselves. Sometimes making residents safer is as simple as making it easier for them to see the toilet.


White floors + White walls + White toilet + Poor depth perception

= a fall
A few suggestions: • Install lights that go on automatically when someone enters the bathroom. (Why? The resident with dementia might not remember where the lights are, and urge incontinent residents don’t/won’t take the time to put the lights on, which will put them at risk for falls.) • Create more of a contrast between the toilet seat and the toilet. • Install grab bars. • Remove mirrors in bathrooms used by residents with dementia (the resident might think someone is in the room with them). By replacing white toilet seats with black toilet seats in a white bathroom, the resident with poor eyesight can see the toilet seat – like a bull’s-eye! 84


Any Underpad Can Protect Your Bedding. Only Ultrasorbs Protects Your Patients.
Current CMS guidelines support the practice of keeping skin dry to prevent skin breakdown and pressure ulcers. Your skin care protocol should include Ultrasorbs, a super-absorbent disposable underpad that actually wicks moisture away from residents’ skin. Advantages of Ultrasorbs: • Keeps skin and bedding dry with absorbency of 3 standard underpads • Super strong, meaning less tearing and fewer linen changes • Cost-effective because you’ll use fewer underpads • Ideal for nighttime open-airing Ultrasorbs underpads are available only from Medline; ask your representative for more information or call 1-800-MEDLINE.

“Ultrasorbs has saved us over 20% in product cost alone because of its extraordinary absorbency and dryness. We went from using an average of 3–4 underpads to just one Ultrasorbs. We were also impressed with the strength and the consistent quality.” DON, Skilled Nursing Facility

1-800-MEDLINE |
©2006 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Incontinence Quality Improvement/ Quality Assurance and Assessment
Regular quality checks can have a big impact on compliance in regards to using the correct incontinence product on each resident. Feel free to use this format when devising your quality improvement forms and program.

1. QAA team assigns staff member to complete audit tool (i.e,. QAA nurse, staff nurse, wound nurse or clinical staff ) 2. QAA team will determine audit frames (i.e., quarterly, monthly or assign one unit per month) 3. QAA team to determine time frame to review findings of audits and target issues from audit (i.e., resolution of issues might be additional education to staff, determine distribution of products, determine if direct caregivers have access to resident sizes to ensure compliance) Below is a form partially filled out. A blank form appears on the next page.

Quality Assurance and Assessment Program Golden Hills Nursing Facility Incontinence Product Utilization




Reviewer’s Signature:

M. Davis RN

QAA Targeted Goal To maintain and ensure compliance with product selection related to resident’s specific type of incontinence

Products used within facility: Briefs Pull-ups Liners Other:
Resident/Room# Incontinent: Yes/No YES Product Utilized Correct Product: Yes/No NO-Tan brief on



Color Code Green White Purple Blue Tan
Feedback related to incorrect product Staff indicates that only tan briefs on cart.

Brief Products Small Medium Regular Large X-Large

Room 120 B Resident: LK


Review distribution schedule with housekeeping and determine if enough supplies have been ordered. Staff educational session completed, related that larger sizes cause more leakage related to poor fit, that each product size of current brief have the same absorbent factors.

Room 122 A Resident: BH



NO-Tan brief on

Attending staff indicated that the larger sizes “hold more urine.”

Follow-up/Conclusion notes:



Quality Assurance and Assessment Program
Facility Name

Incontinence Product Utilization
Reviewer’s Signature:



QAA Targeted Goal To maintain and ensure compliance with product selection related to resident’s specific type of incontinence

Products used within facility: Briefs Pull-ups Liners Other:
Resident/Room# Incontinent: Yes/No Product Utilized Correct Product: Yes/No



Color Code Green White Purple Blue Tan

Brief Products Small Medium Regular Large X-Large

Feedback related to incorrect product


Follow-up/Conclusion notes:

Improving Quality of Care Based on CMS Guidelines


Standard Precautions POLICY & PROCEDURE
I. Policy Standard Precautions are to be followed by all employees for all patients. They are designed to reduce the risk of transmission of microorganisms from recognized sources of infection in the hospital. Standard Precautions protect both patients and employees and include: • treating blood, all body fluids (secretions, excretions [except sweat], non-intact skin and mucous membranes) as infectious regardless of their source, • hand washing before and after patient contact or contact with infectious substances, • using appropriate personal protective equipment (PPE) when there is potential exposure to infectious substances, and • exercising general infection control practices. All body substances (except sweat) are to be treated as infectious regardless of their source. Recognition of potential exposure risks is important. To reduce the likelihood of exposure when dealing with potentially infectious substances, it may be necessary to choose an alternative procedure, technique or equipment. II. Contact Precautions Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are transmitted by direct or indirect contact with the patient or the patient’s environment. A single-patient room is preferred for patients requiring contact precautions. When caring for patients on Contact Precautions the provider should wear a gown and gloves for all interventions that may involve contact with the patient or potentially contaminated areas within the patient’s environment. III. Use of Barriers Hand washing Hand washing is the single most important means of reducing the risks of transmitting microorganisms from one person to another or from one site to another on the same patient. Even if gloves have been worn, hands may become contaminated during glove removal. Wearing excessive jewelry (other than a watch and plain rings) is not recommended during patientcare activities. Antimicrobial soap, water and mechanical friction are sufficient to remove most blood and body substances. Hands must be washed before and after patient contact or contact with items contaminated with blood or body substances. Personal Protective Equipment (PPE) Appropriate PPE is to be worn when there is potential for exposure to infectious substances. PPE is: • gloves, • protective face and eyewear, and • gowns and other protective apparel, such as shoe covers and hats. Gloves Gloves provide a protective barrier and prevent gross contamination of the hands when touching potentially infectious substances. They reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to patients during invasive or other patient-care procedures that involve touching a patient’s mucous membranes and non-intact skin. Gloves must be changed between patients. Wear gloves: • if there is potential for contact with blood, body fluids, secretions, excretions (except sweat), items that may be contaminated with any of these substances, and • if the healthcare worker’s hands are abraded or dermatitis is present. NOTE: Providers who have exudative lesions or weeping dermatitis on their hands must not provide direct patient care. Change gloves: • between each patient, • between tasks and procedures on the same patient after contact with material that may be contaminated, and • when holes or tears are noted. Remove gloves: • after each use, • before touching non-contaminated items and environmental surfaces, and • before treating another patient. Reuse of gloves: • single-use gloves are not to be reused, and • utility gloves may be decontaminated for reuse if the integrity of the glove is not compromised. An intermediate-level disinfectant, phenolic solution, or 70 percent alcohol solution is suitable for decontaminating utility gloves. Utility gloves must be discarded if they are cracked, peeling, torn, punctured or exhibit any signs of deterioration. Selection of gloves: • gloves should be chosen to fit hand size, • flexibility and tactile sensitivity needed during the procedure(s), • the need to follow sterile procedure (sterile vs. non-sterile),



Standard Precautions POLICY & PROCEDURE
• potential for exposure to blood and body fluids during the procedure(s) in terms of the amount and the length of time exposed, • exposure to other substances that break down glove material, such as disinfectants and solvents, and • the amount of stress placed on the glove during the procedure. Protective Face and Eyewear Masks, goggles or face shields must be worn to provide protection of the mucous membranes of the eyes, nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions and to provide protection against the spread of infectious large-particle droplets. Removable sideshields are needed to adequately protect the eyes from blood and body-fluid exposures when wearing prescription glasses. Selecting masks: • check the mask box for the mask’s filtering efficiency, • make sure that the mask will filter to the level of protection that is needed. NIOSH-approved respirators (N-95) should be used when airborne precautions are required, and • do not use adult masks on small children and infants. Wearing masks: • adjust the mask so it fits snugly against the face, is secured along the sides of the face and molded over the bridge of the nose. Air should not enter around the mask edges, • keep beards groomed so that the mask fits closely to the face, • change the mask between patients, • change the mask if it gets wet, • remove the mask as soon as treatment is over, and • do not leave the mask dangling around the neck. Gowns and Protective Apparel Gowns and protective apparel are worn to provide barrier protection and reduce opportunities for transmission of microorganisms. Uniforms and scrubs do not provide adequate protection from blood and body-fluid exposure. Gowns and other appropriate protective apparel must be worn when there is potential that an exposure (contact with contaminated surfaces such as bed linens, or splashing with blood or body fluids) will occur. Selecting gowns and protective apparel: • protective garments should fit, • choose garments that prevent blood or other potentially infectious materials from passing through or reaching the clothes or body, and • select protective garments that are appropriate for the activity and amount of fluid anticipated (refer to AAMI PB70 Level 1 – 4 Guidelines). If the uniforms become soiled with blood or body fluids: • glove and remove clothing immediately, • wash contaminated skin with soap and water prior to changing into hospital scrubs, • place soiled personal clothing in a plastic bag, seal immediately and label for transport home. Once home, place hospital-furnished clothing in plastic linen bag to be returned to the hospital for laundering, and • at home, wash soiled personal clothing separately from other laundry using: 160ºF (71ºC) water and detergent or for water less than 160ºF (71ºC), use detergent and a bleachcontaining product. Mechanical drying of the clothing is recommended. IV. General Infection Control Practices Patient Placement In an ideal setting, each hospitalized patient would have a private room: • patients susceptible to infections due to decreased immune responses such as severe leukopenia may benefit from placement in a private room, • a private room may be necessary to prevent direct or indirect contact transmission when the source patient has poor hygienic habits, contaminates the environment, or cannot be expected to assist in maintaining infection control precautions to limit transmission of microorganisms to a roommate, • patients that may shed large numbers of microorganisms, such as with actively infected or draining wounds, should not share rooms with patients who have fresh surgical wounds, • patients known to be infected with target multidrugresistant organisms should be placed on contact precautions and have a private room. Transport of Infected Patients Limiting the movement and transport of isolated patients within the hospital reduces the opportunities for transmission of disease and microorganisms. Patient-Care Equipment and Articles All patient-care equipment and articles that have become soiled or contaminated with infective material should be handled by employees wearing appropriate PPE. Any disposable item that has become soiled or contaminated with infectious material should be disposed of in the appropriate container. Reusable patient-care equipment and articles that have become grossly soiled or contaminated with infectious material should be covered and decontaminated or sterilized. Linen and Laundry Linen that is soiled or contaminated with infective material should be handled by employees wearing appropriate PPE. Soiled or contaminated linen should be placed directly into impervious plastic linen bags. Soiled linen should be handled as little as possible. Double bagging of linen from isolation and non-isolation rooms is not necessary unless the bag’s integrity has been altered or the outer bag has become soiled with blood or body fluids. Routine and Terminal Cleaning Routine and thorough cleaning and adequate disinfection of rooms, bedside equipment and shared patient equipment should be performed. Regulated Medical Waste All waste should be handled by employees wearing appropriate PPE based on potential exposure risks. Lab Specimens All collected specimens must be labeled and contained in a plastic biohazard lab specimen bag before leaving the collection area.

Improving Quality of Care Based on CMS Guidelines



Guidelines for Use of Overnight Brief
The benefits of a good night’s sleep might outweigh the risk of not being checked and changed every two hours. For residents who have trouble sleeping, the benefits of an overnight brief might include: • Less daytime lethargy • Less fall risk • Less insomnia • Increase in participation in activities • Increase in weight gain

• • • • • Resident-centered care Appropriate utilization of overnight (high-capacity) brief Maintain skin integrity Resident dignity Prevention of sleep deprivation Resident must meet two or more criteria to qualify for a overnight brief Document justification for brief use. Please describe. Be specific. List medications and dosage.

Uses two or more diuretics or is on higher than average dose (greater than 40mg BID) Wet bed or wet clothes consistently after the twohour check period Diagnosis of diabetes, CHF or on tube feeding or intravenous fluids Combative with hands-on care Behavior issues such as wandering if awakened during the night Other comments Family/resident discussion • • • • If used, overnight briefs should be applied at 10 p.m. rounds If used other than at night, care plan should specify times brief used and justification for use Use of overnight brief should be listed on the care plan along with reason for use Examples of problems on the care plan could be “prevent sleep deprivation,” “improved sleep pattern,” “maintain resident dignity,” “maintain skin integrity,” “prevention of behavioral episodes” • Enclose a copy of this form with the care plan Date
Adapted from Soldiers’ Home in Holyoke, Holyoke, MA One facility’s effort in individualized care for residents with incontinence, behaviors, and sleep disturbances.



What, When, Where and Why...
Because one of the biggest concerns with isolation protocols is using the right combination of products at the right time, we've taken the liberty of showing the various levels below.

Level 1: Gown and Gloves
• • • • Housekeeping Maintenance Food Service Daily care for patients with no serious illness

Level 2: Gown, Gloves and Mask
• Infected patient with airborne disease • Nurse cleaning the patient • Patients with antibiotic-resistant bacteria, hepatitis A, scabies, impetigo or lice • Patients themselves moving away from isolation should wear mask, as well as visitors • Patients who require droplet precautions

Level 3: Gown, Gloves, Mask and Eye Protection
• Healthcare providers caring for patients with excessive fluids • Blood, body fluids, secretions (such as phlegm), excretions (such as urine and feces), nonintact skin and mucous membrane

For more information, go to or call 1-800-MEDLINE

Try Our Web Tools!
Here is a helpful list of Web sites recommended by our Wound Care Advisory Board members: Medline advanced skin and wound care The Anna and Harry Borun Center Gerontological Research at UCLA National Pressure Ulcer Advisory Panel American Professional Wound Care Association Agency for Healthcare Research and Quality Wound, Ostomy and Continence Nurses Society Association for the Advancement of Wound Care Symposium on Advanced Wound Care American Medical Directors Association

Don’t forget that if you have question about a particular product, the manufacturer of the product might have helpful information on their Web site.



Wound Care Product Selector Selecting an appropriate wound care dressing can be a challenge, particularly when your clinical staff or usual resources are not available. Medline has used the convenience of the Internet to develop programming that can be accessed anywhere, anytime. Simply go online to receive assistance in dressing selection using the Wound Care Product Selector at The program will ask questions about the wound, such as depth, drainage and periwound skin and suggest appropriate dressings that meet current standards of practice.

1 2 3 4 5
Improving Quality of Care Based on CMS Guidelines 93

The Web site asks questions about the condition of the wound.

Each question leads logically to the next, following a decision-making algorithm designed by CWOCNs and other clinical experts.

With the information that is gathered, the program suggests dressing options that are consistent with standards of practice for wounds with those characteristics.

Residents are identified as potential Butterfly Watch by the management team. The resident is reviewed during the “Resident at Risk” weekly meeting. If a resident has 2 or more ‘indicators’ (as listed below), the resident may be placed on a 14-day observation period and added to the Butterfly Watch. Weight loss Decubitus ulcer Falls Infections Change in mental status Change in level of function Continence status After completion of the 14 day observation, a determination will be made for a “Significant Change” or admission to the “Butterfly’s Are Free” program. The Admissions Office will be informed concerning the resident’s status. This information will be added to the daily census report which is available to the management team each morning.




DATE INITIATED Social Services Nursing


PR OBLEMS AND STRENGTHS Is in the End of Life stage related to

Resident will not undergo unnecessary medical interventions or transfers. Resident s comfort will be considered with each intervention to ensure he/she remains as comfortable as possible. (E.g. labs, weights, vital signs, etc.) Will not be hungry or thirsty. Nursing Dietary

Is expected to have an increased decline in condition, which is unavoidable Will not exhibit signs or symptoms of anxiety

Will remain pain free and comfortable as possible


Improving Quality of Care Based on CMS Guidelines




Review Advance Directives Continue to review resident preferences Review effectiveness of current treatment plan Provide options and choices Attempt to provide symptom management on site Eliminate unnecessary treatments per resident wishes Report any change in condition Offer foods and fluids as ordered Offer comfort foods and fluids of choice if dietary restriction is lifted Ask family for favorite foods Family to bring in favorite food as allowed and as able Offer nutrition and hydration to residents tolerance and desire Assess pain qs and prn; offer pain medications Assess pain more frequently as condition dictates Medicate as ordered Monitor for non-verbal signs and symptoms of pain and report changes to nurse Monitor anti-anxiety medication effectiveness; change orders as needed Involve resident in pain management by asking for feedback regarding the level of pain, (as able) using a 1 to 10 scale or visual analog Involve family in pain management through observation of non-verbal signs of pain such as guarding, wincing or moaning Notify MD or ARNP of pain or discomfort that is not alleviated Provide bedside activities such as therapeutic massage, aroma-therapy, music of choice, visual imagery, and document

GOALS APPR OACHES DISC Social Services Nursing Resident will not undergo unnecessary medical interventions or transfers. Resident s comfort will be considered with each intervention to ensure he/she remains as comfortable as possible. (E.g. labs, weights, vital signs, etc.) Will not be hungry or thirsty. Nursing Dietary Will remain pain free and comfortable as possible Nursing Will not exhibit signs or symptoms of anxiety Review Advance Directives Continue to review resident preferences Review effectiveness of current treatment plan Provide options and choices Attempt to provide symptom management on site Eliminate unnecessary treatments per resident wishes Report any change in condition Offer foods and fluids as ordered Offer comfort foods and fluids of choice if dietary restriction is lifted Ask family for favorite foods Family to bring in favorite food as allowed and as able Offer nutrition and hydration to residents tolerance and desire Assess pain qs and prn; offer pain medications Assess pain more frequently as condition dictates Medicate as ordered Monitor for non-verbal signs and symptoms of pain and report changes to nurse Monitor anti-anxiety medication effectiveness; change orders as needed Involve resident in pain management by asking for feedback regarding the level of pain, (as able) using a 1 to 10 scale or visual analog Involve family in pain management through observation of non-verbal signs of pain such as guarding, wincing or moaning Notify MD or ARNP of pain or discomfort that is not alleviated Provide bedside activities such as therapeutic massage, aroma-therapy, music of choice, visual imagery, and document All





PR OBLEMS AND STRENGTHS Is in the End of Life stage related to

Is expected to have an increased decline in condition, which is unavoidable

Resident and family bereavement concerns will be addressed Resident will have a peaceful death in the facility in accordance with expressed wishes.

Evaluate resident / family needs and make necessary referrals to clergy or spiritual support persons as requested. Provide opportunity for prayer and meditation support as indicated Provide bedside activities that distract the resident such as ________________________________ ________________ per the resident s preference and tolerance Provide humor therapy for resident and family Contact hospice if desired Provide private time for relationships while minimizing resident and family isolation Chaplain services provided as desired Elicit or confirm resident or surrogate goals and values for life prolonging interventions. Nursing Social Services Nursing Social Services

RESIDENT ___________________________________________________________ ________________________________


Improving Quality of Care Based on CMS Guidelines

DATE OF ADMISSION __________________________________________________ ____________________________________




Healthy Skin Interview: Success Stories with Incontinence Care continued from page 25 Q – DT: What types of outcomes have you seen? A – PQ: We have witnessed cost containment by using the appropriate product. We’ve also seen less skin breakdown. Certainly resident and family complaints have gone down. Each care center now has a bladder scanner, which helps to identify urinary retention. Veterans are administered cranberry tablets for UTI prevention. We continue to look for a downward trend in the number of UTIs. Presently, numbers are not increasing. Q – DT: How often does your bowel and bladder team meet and what are your current targeted issues? A – PQ: Staff compliance is an ongoing issue. We need to provide constant reinforcement. Performing monthly performance improvement checks has really helped. The team also receives budget versus spending information from the business office so if incontinence costs have increased, we can track down and solve the problem. Currently, the team is meeting monthly in order to gain control of product compliance with the main issue being the misuse of the overnight (high-capacity) brief. Q – DT: What are some of your concerns regarding the use of your high-capacity brief? A – PQ: The overnight brief is extremely absorbent and can hold very large voids, which is fantastic. But our staff was misusing this brief, using them on all veterans instead of targeting those who really needed them. Subsequently, costs went up. It became a compliance issue on all shifts. It might be partially due to poor performance on the part of a few staff members who did not want to change veterans when incontinent. The team has implemented a tool titled Guidelines for Use of Overnight/High Capacity Brief (see Forms & Tools page 90). It integrates the following components: the veteran’s diagnosis (e.g., diabetes, CHF, tube feedings) and medication regimen (e.g., diuretics, behavioral issues, wandering during sleep). We identify those who qualify for use of the overnight brief. Then we include justification within the care plan with rationale, including prevention of sleep deprivation, maintenance of skin integrity and preservation of veteran dignity. Currently, performance improvement data has shown marked improvement, with 100 percent compliance in the last two months. Q – DT: Not all facilities have access to bladder scanners. How do you use them? A – PQ: We use our bladder scanner as part of the resident’s admission assessment to test for overflow incontinence by measuring the post-void residual (PVR). We are lucky to have a urology clinic within the outpatient portion of the facility. The urologists frequently request our staff to check for PVR. We also can use the bladder scan if a veteran has not voided in eight hours. If the reading is greater than 250ml, a straight catheter is used to relieve retention. To meet the needs of our population, administration supported the purchase of bladder scanners for all four care centers. Q – DT: What areas do you see your committee working on in the future? A – PQ: Toileting residents is still an area that can always be improved, particularly since our building design doesn’t include as many bathrooms as we’d like. It’s interesting to think about how times have changed. Years ago our primarily male population could hang plastic urinals on their wheelchairs no matter where they went. This resulted in more self-toileting, but the filled urinals were everywhere! Currently, our staff focus is to know a resident’s individual voiding pattern so that even if he is off the floor, we can track him down whether to help him with the bathroom or to check and change him. The future for us holds even more resident-centered care as we embrace culture change and train our staff using the LEAP* program, which is resident driven. The bowel and bladder team will continue to meet regularly and tackle problems as they come up.
*LEAP is a program designed by Mather LifeWays to educate, empower and retain staff by using a resident-centered approach.

Word Search Answers



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