Improving Quality of Care Based on CMS Guidelines

Volume 3, Issue 4

Butterflies are Free:

Exceptional End
of Life Care
Jumpstart Wound Healing
with COLLAGEN

7
Forms and Tools:

Great
Stategies
to
Improve
Care
CMS
Targets Psychosocial Outcomes
Insight on Organization
& Balance from Author
Julie Morgenstern
CROSSWORD PUZZLE FOR CE CREDIT, PAGE 38!
Most occlusive dressings do a good job of managing moisture,
but unfortunately they can also contribute to wound odor.
Now there's a new option. . .
Introducing Exuderm® OdorShield™ -
the first o dor-control hydrop olymer
This patented new dressing uses naturally occurring
cyclodextrins, which are noncytotoxic molecules that
absorb odor and wound exudate. It is the only dressing
that combines the benefits of an advanced moisture man-
agement with powerful odor control.
More effec tive than charcoal
The Exuderm OdorShield dressing outperformed leading
charcoal-based dressings in laboratory odor absorption
tests.* While charcoal's odor-absorbing properties are
deactivated by the proteins in wound exudate,
Exuderm OdorShield's are actually enhanced. Other
advantages: Exuderm OdorShield is conformable,
absorbs more fluid than charcoal dressings and
requires no secondary dressing.
An improvement on yesterday's hydrocolloids
Exuderm OdorShield eliminates the major drawback of
traditional hydrocolloids: their distinctive odor upon
removal. It effectively absorbs exudate and provides a
protective, occlusive barrier that promotes wound healing.
Features include a tapered edge and low-friction backing
to help prevent rollup and extend wear time.
Ask your Medline representative
for more information on
Exuderm® OdorShieldTM dressings.
1-800-MEDLINE | www.medline.com
In Canada c all 1-800-396-6996
*Data on file.
©2006 Medline Industries, Inc. Exuderm and Medline
are registered trademarks and OdorShield is a
trademark of Medline Industries, Inc.
 HEALTHY SKIN
Improving Quality of Care Based on CMS Guidelines

Editor Contents
Sue MacInnes, RD, LD
SURVEY READINESS
Clinical Editor 13 Ask Molly
Margaret Falconio-West, BSN, RN, APN/CNS, 14 CMS and Psychosocial Outcomes
ET, CWOCN, DAPWCA 22 Healthy Skin Interview
28 The Wait Is Over: CDC Introduce New Guidelines for
Clinical Team Management of MDROs in Healthcare Settings
Cynthia A. Fleck, RN, BSN, ET/WOCN, 46 How Good Are You at Assessing Risk? Sharpen Your Skills with
CWS, DAPWCA, MBA, FCCWS the Braden Scale
50 Managing Dementia-Related Incontinence Page 6
Janet L. Jones, RN, BSN, PHN, ET, CWOCN,
64 Documentation: Using the Best Words for You and Your Resident
DAPWCA
Barbara Leonard, MSN, RN, CWOCN, CWS TREATMENT
Joyce Norman, RN, BSN, CWOCN, DAPWCA 20 Can a Cranberry a Day Keep UTIs Away?
34 Chronic Wounds: Collagen Might Be the Answer
Elizabeth O’Connell-Gifford, RN, BSN, 55 Pressure Relief: A Concept of the Past
CWOCN, DAPWCA, MBA 56 Product Spotlight: Foam Dressings
Carol Paustian, RN, BSN, ET, CWOCN,
DAPWCA SPECIAL FEATURES
6 Butterflies are Free
Amin Setoodeh, BSN, RN 32 Do It RIGHT! Joint Commission Releases Pressure Ulcer Page 14
Jackie Young, RN, BSN, ET, CWCN, Prevention Video
DAPWCA 42 Making Sense of Research Reports
68 Oh,Your Aching Back
Wound Care Advisory Board 79 What’s in a Name?
Anne Blackett, MS, RN, COCN, CWCN, 82 Healthy Skin Word Search
CPHQ, CNS
Pat Emmons, RN, MSN, CNS, CWOCN FORMS & TOOLS
84 Functional Incontinence
Beatrice Etzel, MSN, APRN, BC, CWOCN 86 Incontinence Quality Improvement/Quality Assurance and Assessment
Lynne Grant, CNS, MS, RN, CWOCN 88 Policy & Procedure Page 34
Pam McFarland, RN, CWCN, OCN 90 Guidelines for Use of Overnight Brief
92 Use Our Web Tools
Andrea McIntosh, RN, BSN, CWOCN, APN
94 Butterfly Watch
C.C. Monge, RN, MS, DABFN, CWOCN 95 End of Life Care Plan
Susan Morello, RN, BSN, CWOCN
CASE STUDY
Susan Wood, PhD, RN, WOCN
40 Use of Ionic Silver and Collagen to Reduce Bioburden and
Promote Healing for Improved Quality of Life in a Complex Patient
© 2006 Medline Industries, Inc. Healthy Skin
Page 68
is published by Medline Industries, Inc. REGULAR FEATURES
One Medline Place, Mundelein, IL 60060
1-800-MEDLINE (633-5463)
4 Letter from the Editor
5 News Flash
38 CE Crossword Puzzle: Collagen Dressings in Chronic Wounds
60 Hotline Hot Topic

CARING FOR YOURSELF

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

ABOUT MEDLINE
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, www.medline.com.

Improving Quality of Care Based on CMS Guidelines 3

 HEALTHY SKIN I Letter from the Editor
D
DEAR READER,
To continue to bring you the hottest infor-
mation 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 preven-
tion. The Joint Commission (formerly referred
to as JCAHO) recently released an educational
program on the prevention of pressure sores-
see 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 chal-
lenging wound and new technology in
foam dressings.
4 HEALTHY SKIN
We realize good skin care and prevention
include other components such as resident-
centered 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
We all can agree
article that demonstrates the impact excep-
that we should do
tional care has on your staff, the resident
and their family. Nina Willingham, adminis- things right…but
trator of Life Care Centers of Sarasota, it is our goal to
Florida, reminds us about what health care make it hard for
is all about and how to make a difference the healthcare
in people’s lives. worker to do
things wrong.
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,
Sue MacInnes
 REGULAR FEATURES

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
CPSC Sets New Mattress
• Reduce surgical complications Flammability Standards
• Prevent pressure ulcers
• Deliver reliable, evidence-based care for congestive heart failure
The Consumer Product Safety
• Get Boards on board
Commission has issued a flammability
For more information on the new campaign, visit www.ihi.org. standard for mattresses as part of the
Flammable Fabrics Act. All mattresses
CDC Releases New Guidelines on MDROs manufactured, imported or renovated on
The Centers for Disease Control and Prevention has released or after July 1, 2007 will need to conform
its long-awaited updated guidelines on multidrug-resistant
to the new standard.The goal of the new
organisms in healthcare settings. The guideline contains
specific recommendations designed to halt the progressive requirements is to create mattresses that,
increase in MDROs that began to be seen in the early in the event of a fire, generate a smaller
1990s. The guidelines contain two tiers of recommenda-
size of fire with a slower growth rate,
tions. The first tier includes general recommendations and
the second details intensified interventions for use in the which in turn would reduce the possibility
event that the first-tier recommendations are not effective. of flashover occurring.The Commission is
Each tier consists of the same seven control measures:
administrative, MDRO education, judicious antimicrobial use,
estimating that the new standard could
surveillance, infection control precautions, environmental possibly eliminate 240–270 fire-related
and decolonization. deaths and 1,150–1,330 fire-related
For more on this topic, please refer to “The Wait Is Over:
injuries annually. For
CDC Introduce New Guidelines for Management of more information on
Multidrug-Resistant Organisms in
the new standard, visit
Healthcare Settings” in this issue of
Healthy Skin or visit www.cdc.gov. www.cpsc.gov.

Improving Quality of Care Based on CMS Guidelines 5

Butterflies
are
Free
≤
By Nina Willingham, CNHA

6 HEALTHY SKIN

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 end-
of-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.
Improving Quality of Care Based on CMS Guidelines
SPECIAL FEATURES
≤
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-of-
life 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)
www.aacn.nche.edu/elnec
California Coalition for Compassionate Care (CCCC)
www.finalchoices.calhealth.org
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 self-
assessment 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
7
 DO YOU KNOW IF YOUR
FACILITY IS SURVEY-READY?
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) To learn more about Compass, contact your
• Continuous Pressure Ulcer Prevention booklets (to improve Medline representative or call 1-800-MEDLINE.
www.medline.com
communication and documentation)
©2006 Medline Industries, Inc. Medline is a registered
trademark of Medline Industries, Inc.
 Butterflies
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.
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 com-
• Families didn’t know what to expect from the dying pletion of a 14-day observation period (based on the
process and were reluctant to accept their loved above criteria), a determination is made for a significant
ones’ approaching deaths. change in status or admission into the program. If residents
• Financial strain on residents and their families were have a sudden decline in condition, they can be admitted
posed by end-of-life programs already operating in into the program.
the community.
• Our associates felt just as uncomfortable with the Notification
dying process as the families because of a lack of The resident and family are notified of the program and
education and experience. education is provided on the program’s stages and what
to expect in the dying process. Hospice consult is also
We assembled an interdisciplinary team to set our mission offered. The resident or legal decision maker provides
and our goals, including the executive director, director of signed consent to participate in the program.
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 9

 Assessment
Butterflies
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 high-
lighted. 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.
10 HEALTHY SKIN
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 three-
drawer 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 Meeting the spiritual needs of the dying resident is very important.
medication can be given. Here, an associate is reciting the Lord's Prayer with a resident.

Moving Through the Process To learn the step-by-step details of how you can set up
As the resident moves through the dying process, the care a Butterflies are Free program in your facility, contact Nina
plan is constantly updated. Making changes to the texture Willingham at Nina_Willingham@lcca.com.
of food is important, and comfort foods are added as
desired. (Cookies and ice cream is the number one We have included a sampling of the Butterflies are Free
requested comfort food, and associates are quick to fill forms starting on Page 94.
those requests.) Routine medications are normally discon-
tinued 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 Looking for more?
This Day, with stories and devotionals geared toward Visit www.medline.com/butterflies
helping the family cope with the death of a loved to browse the complete program
one, is mailed to the family, along with a cedar and its accompanying video.
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.

Improving Quality of Care Based on CMS Guidelines 11

ies 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
www.medline.com/butterflies 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.

12 HEALTHY SKIN
 SURVEY READINESS
Ask
Molly
advice from a former surveyor

Q
I have heard that surveyors have been issuing fines to nurses accepted, adopted or promulgated by recognized professional
for things like using veterinary product on skin. I hear one organizations or national accrediting bodies.” Standards
nurse was fined $1,000. Is this true? Can individual nurses of practice describe the responsibilities of healthcare profes-
be fined by CMS surveyors? sionals and are based on the values, priorities and practice
of a profession and describe the minimal standards of
Amanda R., DON performance against which actual performance can be
Dallas, Texas compared. Standards of practice also promote consistency
and quality and encourage a common, systematic approach
Dear Amanda, based on the most current scientific evidence.

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 infection-
control 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
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).

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 morandgrp@aol.com.

Improving Quality of Care Based on CMS Guidelines 13

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

By Molly Morand, RN, BSN, BC

14 HEALTHY SKIN
 SURVEY READINESS

Improving Quality of Care Based on CMS Guidelines 15

“
a greater psychosocial outcome.”1
Since the severity of the psychosocial
A resident outcome of the resident being
slapped was higher than the physical
outcome, the psychosocial outcome
who was slapped would be used as the level
by a staff member of severity.
may experience CMS Stresses Importance
of Physical and Psychological
only a minor Outcomes
physical outcome Although some residents might
experience either a negative physical
from the slap but or psychosocial outcome, others
might experience both. With the
suffer a greater release of the Psychosocial Outcome
Severity Guide, CMS is clearly
psychosocial
”
stating that physical outcomes
outcome. (such as a pressure ulcer) and
psychosocial outcomes (such as
embarrassment) are equally impor-
tant 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
16 HEALTHY SKIN
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 unsuc-
cessful 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 Surveyors will evaluate each resident’s
resident’s psychosocial response to
the noncompliance. This will then
psychosocial response to the noncompliance,
be the basis for determining psy- and this will then be the basis for determining

chosocial 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 partici-
pation logs and physician progress
notes. The survey team will deter-
mine 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.
psychosocial severity of a deficiency.
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 circum-
stances 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,
”
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.

Improving Quality of Care Based on CMS Guidelines 17

 Clarificationterms
of
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
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.
Severity Level 4 Considerations:

4
that do not come from a feared source. Immediate Jeopardy to Resident
Health or Safety
Apathy refers to a marked indifference to the environment; • Sustained and intense crying,
lack of a response to a situation; lack of interest in or moaning, screaming or
concern for things that others find moving or exciting; combative behavior.
absence or suppression of passion, emotion or excitement. • Expressions (verbal and/or
nonverbal) of severe,
Anxiety refers to the apprehensive anticipation of future unrelenting, excruciating
danger or misfortune accompanied by a feeling of and unrelieved pain; pain
distress, sadness or somatic symptoms of tension. has become all-consuming
Somatic symptoms of tension may include, but are not and overwhelms the resident.
limited to, restlessness, irritability, hypervigilance, an • Ongoing, persistent expression
exaggerated startle response, increased muscle tone and of dehumanization or
teeth grinding. The focus of anticipated danger may be humiliation in response to
internal or external. an identifiable situation, that
persists regardless of whether
Dehumanization refers to the deprivation of human the precipitating event(s) has
qualities or attributes such as individuality, compassion ceased and has resulted in a
or civility. Dehumanization is the outcome resulting from potentially life-threatening
having been treated as an inanimate object or as having consequence.
no emotions, feelings or sensations.
Severity Level 3 Considerations:

3
Depressed mood (which does not necessarily constitute Actual Harm That Is Not
Immediate Jeopardy
clinical depression) is indicated by negative statements,
• Persistent depressed mood
self-deprecation, sad facial expressions, crying and tear-
that may be manifested by
fulness, withdrawal from activities of interest and/or
verbal and nonverbal
reduced social interactions. Some residents such as those symptoms such as:
with moderate or severe cognitive impairment may be - Social withdrawal;
more likely to demonstrate nonverbal symptoms of irritability; anxiety;
depression. hopelessness; tearful-
ness; crying; moaning;
Humiliation refers to a feeling of shame due to being
- Loss of interest or ability
embarrassed, disgraced or depreciated. Some individuals to experience or feel
lose so much self-esteem through humiliation that they pleasure nearly every
become depressed.”1 day for much of the day;

18 HEALTHY SKIN
 • 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.
Severity Level 2 Considerations:
2
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).
Severity Level 1 Considerations:
1
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 psychoso-
cial 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
Putting the New Psychosocial
Guide into Practice
Facilities have always put a lot of
focus on residents’ physical health
– preventing pressure ulcers, treat-
ing incontinence, etc. However,
with the release and implementa-
tion 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 require-
ments, 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 opportu-
nities related to psychosocial
interventions and
• Including questions regarding
psychosocial care in customer
satisfaction surveys
Improving Quality of Care Based on CMS Guidelines
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 resi-
dents’ 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:
http://www.cms.hhs.gov
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 consult-
ing 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 morandgrp@aol.com.
19
 TREATMENT
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.
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.
20 HEALTHY SKIN
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 www.cranberryinstitute.org.
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.
 Get serious about skin care with

disposable briefs

Restor
e
an inc briefs fit p
ontine erfect
that c n ly
ompli ce care pr into
es wit otoco
h CMS l
F315.

> Treated with Remedy Skin Repair Cream to nourish and protect skin
Medline’s Remedy Skin Repair Cream is applied to the entire length of the
Restore brief’s inner liner as part of the manufacturing process. This exclusive,
all-natural cream helps to prevent skin breakdown. It restores and maintains
skin’s natural moisture balance while delivering vital nutrients to the skin.

> Packed with features for great performance

Restore briefs have a super-absorbent “Ultra Care” core for maximum dryness,
plus antileak leg cuffs to protect clothing and bedding. Refastenable tape tabs
with new “grab anywhere” technology allow a secure fit and help reduce waste.
And a soft, clothlike outer cover helps prevent irritation and rashes.

Ask your Medline representative about Restore briefs today.

1-800-MEDLINE
©2006 Medline Industries, Inc.
Restore…the disposable brief that helps One Medline Place, Mundelein,
keep skin healthy and dry! IL, 60060.
www.medline.com
 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.

ie s
o r
St
ss
ce
uc Care
S tine nce
con
th In
wi

Interview by Deb Tenge

RNC, MS, CWOCN

22 HEALTHY SKIN
 SURVEY READINESS

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
Soldiers’ Home facility 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.

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 23

 Problem
• Incontinence budget out of control • Leakage and odors
• Inconsistent product usage on residents • Skin problems related to incontinence
• Complaints from residents and families

Solution
• Education of staff • Spreadsheet calculates par levels for each unit so delivery is correct
• Assessment and proper sizing • Monthly quality improvement checks encourage staff compliance
• List of residents, product used, size used

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.
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.

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, Judy Pickford makes sure that the right-sized product is used on
where there is a higher rate of staff turnover. the right resident by checking the list.

24 HEALTHY SKIN
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 develop-
ment 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 better-
performing 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.
Improving Quality of Care Based on CMS Guidelines
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 distri-
bution 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 iden-
tification 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
25
• Introducing Medline's new Green Tree line of toilet paper and hand towels
made of 100% recycled material because we care.
• Medline is doing its share to help the environment, can we count on you
to help?
• Ask your Medline Rep for more details about
this program.
Call 1-800-MEDLINE
 Did you know…
• Each person uses approximately 700 pounds
of paper products per year?
• Paper accounts for 40 percent of all waste?

Why recycle?
By recycling one ton of paper, you save:
• 17 trees • 687 pounds of air pollution
• 6,953 gallons of water • 3.06 cubic yards of landfill space
• 463 gallons of oil • 4,077 kilowatt-hours of energy

More to think about

• If every household in the United States replaced just one roll of
virgin fiber toilet paper (500 sheets) with 100 percent recycled
paper, we could save 423,900 trees!

• Nearly half of the trees cut in North America go to papermaking.

• Recycled paper also needs less bleaching than virgin paper.

Medline Green Tree products are produced without using chlorine
compounds (PCF – process chlorine free), which are highly toxic.

• Producing recycled paper causes 74 percent less air pollution, 35

percent less water pollution and creates five times the number of
jobs than producing paper from trees. It saves old-growth trees,
forest ecosystems, native habitat and biodiversity.
By Alecia Cooper, RN, BS, MBA, CNOR

28 HEALTHY SKIN

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.
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 signif-
icantly impact colonization, infection, treatment, costs
and ultimately morbidity and mortality, measures have
been defined to control and stop their transmission.
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.
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
Improving Quality of Care Based on CMS Guidelines
SURVEY READINESS
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
• 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,
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
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)
29
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
Example: At present, five residents in your long term
care facility have been diagnosed with MRSA. Tier 1 rec-
ommendations are successfully implemented. In three
months, you still have five residents with MRSA and an
additional resident is diagnosed with MRSA.
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
To read the new CDC MDRO guidelines
in their entirety, go to www.cdc.gov.
30 HEALTHY SKIN
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 www.medline.com 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-
tency quiz so you can gauge how you rate against others!
Medline’s Ami
demonstration
Right now, www.medlineuniversity.com 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.)
Medline’s Ami doll
Reference
Centers for Disease Control and Prevention. Management of
Multidrug-Resistant Organisms In Healthcare Settings, 2006.
Available at: www.cdc.gov. Accessed November 28, 2006.
MEDLINE UNIVERSITY
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 www.medlineuniversity.com to learn more.

 Joint Commission Releases
Pressure Ulcer Prevention Video
By Margaret Falconio-West
BSN, RN, APN/CNS, ET, CWOCN, DAPWCA

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

32 HEALTHY SKIN

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 hospitaliza-
tion. 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 proj-
ects 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.
The National Patient Safety Goals
for 2007 include:
Goal 14 Prevent health care-associated
pressure ulcers (decubitus ulcers)
14A Assess and periodically reassess each
resident’s risk for developing a pressure
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.
Improving Quality of Care Based on CMS Guidelines
SPRECIAL FEATURES
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.
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 www.ihi.org/campaign.
For more information, please visit
www.jcrinc.com, click Education and
then click Videos/DVDs.
33
 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

34 HEALTHY SKIN
 TREATMENT

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 35

 Let’s take a look at
the normal healing process
Normal wound healing involves three specific but overlap-
ping 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 manu-
facture 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
I f you are seeing a
chronic wound in
humans, accounting for nearing 70 percent of all protein. It is one of the components that largely
fill the wound in normal healing. Elastin, another protein, provides strength and elasticity to the
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
still present. Possibly destructive with less-scarred, normal-appearing tissue.
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. TIMPs are described as MMPs, keeping the MMPs occupied
• Matrix metalloproteases “anti-MMPs” and must in the activity of breaking down the
(MMPs). The MMPs are outnumber the MMPs (concep- dressing material instead of the new
proteases that are associated tually speaking) for the wound (de novo) collagen made by the
with metal ions, and the worst to heal normally. In a chronic fibroblasts working hard in a chal-
of them are specific to collagen wound, the MMP to TIMP ratio lenging environment. The enzymes
or fragments of collagen, is in favor of these collagen- are concentrated in the dressing,
meaning that they seek out destroying enzymes, MMPs. where collagen is plentiful, instead
collagen molecules and of in the tissue, where the fibrob-
chemically break them down. How should you handle lasts are putting out the body’s own
• Elastase destroys other enzymes this problem? collagen at low concentrations.
too – those that could be Bring fibroblasts to the wound that Denatured collagen, available in
useful to the wound, such as will produce fresh collagen and fill some wound care products today,
tissue inhibitors of matrix the wound bed. A very effective is processed chemically to the
metalloproteinases (TIMPs). method is to plant native collagen extent that it has lost the sophisti-
dressings that will bind with the cated triple helix structure of the

36 HEALTHY SKIN
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 three-
dimensionally (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 There is a good chance that the
importantly, elastase is known to chronic but infection-free wound
play a role in creating the final that mystified you in refusing to
destructive form of MMPs. Taking heal, even when you tried every-
elastase out of play seriously thing else, including addressing
reduces the potential of MMPs all other associative factors, will
being freshly and efficiently created now proceed to healing.
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 fibrob-
lasts. 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.
Improving Quality of Care Based on CMS Guidelines 37
 You can receive one CE contact hour by completing the crossword!
CE Crossword Puzzle
Collagen Dressings in Chronic Wounds

Objectives of Instructions:
After you read the article “Chronic Wounds,” complete the crossword puzzle.
Education: To receive your CE credit, you will need to go online to the Web site

1 Understand how collagen

dressings can help a
www.medline.com 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
chronic wound
with CE Broker).

2 Differentiate between the

phases of wound healing
Continuing education is valid through December 31, 2007. CE credit
is provided through California Board of Registered Nursing and Florida
Board of Nursing.

3 List two proteins that

contribute to new tissue
developement

38 HEALTHY SKIN
 REGULAR FEATURES
Across
3 The collagen in a collagen wound dressing ____ to the Chronic Wound FAQs
destructive enzymes
5 Chronic wounds that are not infected often respond well to this How many people have
type of dressing chronic wounds?
6 If MMPs are bad enzymes, then TIMPs are _____ enzymes
It is estimated that nearly 5 million
8 The extracellular _____ (ECM) consists of collagen and elastin
Americans suffer from chronic wounds.1
9 An enzyme that destroys elastin
13 Fibroblasts produce fresh collagen and fill the _____ bed
What are the causes of
14 Proliferation is the second _____ of healing
chronic wounds?
15 MMPs seek out _____ and break it down into fragments
17 Inflammatory phase typically lasts two to three ______
The majority of chronic, non-healing
18 Denatured collagen no longer has the triple ____ structure wounds can be linked to diabetes,
20 Neutrophils help clean the wound but also secrete _______ which immobilization, chronic edema and
can be detrimental in a chronic wound circulatory problems. Approximately 1.5
21 Protein that provides strength and elasticity to skin million people with non-healing wounds
22 Must outnumber MMPs in order for wound to heal normally have diabetes, and another 2.5 million
24 Main function is to manufacture proteins, growth factors and have pressure ulcers. Chronic wounds
angiogenic factors can also result from traumatic injury,
27 Type of collagen dressing that is effective in attracting MMPs non-healing surgical incisions or other
28 Epithelialization is when new _____ migrate over the surface of diseases affecting the skin.1
the healing wound
29 Bad enzymes will migrate to the plentiful collagen in a
How can a chronic wound
collagen ______
be identified?
A wound is considered chronic if it has
Down
not improved significantly in four weeks
1 How many phases in normal wound healing?
or completed the healing process in
2 The first phase of healing
4 Collagen and elastin are both ______
eight weeks.1
7 The final phase of wound healing
Reference
10 Byproducts of MMPs’ destruction of collagen dressings are
1 Center for Wound Healing & Hyperbaric Medicine.
collagen _____
Frequently asked questions. Available at:
11 Destructive _____ in the wound may prevent normal
http://www.woundhealingcenter.org/faq.htm.
wound healing
Accessed December 18, 2006.
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

Improving Quality of Care Based on CMS Guidelines 39

Use of Ionic Silver* and Collagen+ to Reduce
Bioburden and Promote Healing for Improved
Quality of Life in a Complex Patient
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.
40 HEALTHY SKIN
Study # LIT467
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.
 CASE STUDY
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 RESULTS
perineal/perianal area extending to the buttocks. After careful assessment the Even though the double incontinence is a daily
decision was made to aggressively treat this wound. A protocol was written that issue, her menses a monthly issue, and the
would not only provide an optimal moist wound healing environment, but also potential for bacterial bioburden are present,
address debridement necessary and the bacterial bioburden. The treatment plan
her wounds are improving. This case
included wound cleansing, debridement, and the use of ionic silver hydrogel
demonstrates that even under complicated
with bovine collagen particles. The ionic silver hydrogel and the collagen were
mixed together and applied to the wound daily to every other day. 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.
Sacral Wound Measurements, showing almost 95% decrease in the wounds
overall dimensions in approximately eight months
CONCLUSION
Even the most challenging wounds can be
Date Measurement (L xW) Undermining (9:00 – 11:00)
assessed, addressed, and treated with a little
7-11-05 20 x 15 6.5 cm ingenuity and choosing the right treatment
8-31-05 10.5 x 6.2 4.8 cm regime. Dressings that serve several functions,
10-26-05 10.5 x 4.9 3 cm such as the ionic silver hydrogel in
12-28-05 8.8 x 4.4 3 cm combination with the collagen particles,
3-1-06 8 x 2.5 3 cm provided the best healing environment for this
difficult wound. We will continue to use this
3-22-06 8x2 3 cm
product combination in our clinic as a viable
option for all chronic wounds.

Over a period of eight months, this photographic series shows the progress
REFERENCES
of a complicated sacral wound. Overall, the wound decreased 95% and
Baranoski S and Ayello E. Wound treatment
helped improve the quality of life for this 46 year old paraplegic female.
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.
7-11-05 8-8-05 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.

*Arglaes Powder from Medline Industries, Inc.

Mundelein, IL Arglaes is a registered trademark of
Giltech, Ltd. +Medifil Particles from BioCore, Kansas
City, KS.
11-30-05 3-1-06

Improving Quality of Care Based on CMS Guidelines 41

 Making Sense of
Research
Reports
By Carol Paustian
BSN, RN, ET/CWOCN, DAPWCA

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.

42 HEALTHY SKIN

How do we evaluate studies?
The best studies are set up so the control and interven-
tion groups are receiving the same intervention with only
one variable.
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 inter-
vention. 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.
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 impor-
tantly, 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.
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
SPECIAL FEATURES
Case report (commonly called case study). This is a
clinician’s report of 1 or 2 patients and how they responded
to the intervention.
A case series is made of several (usually at least three)
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
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.
A placebo is an inactive substance often used in pharma-
ceutical studies. One group will receive the test medication
and the other will receive a non-medicated “drug” that looks
and possibly smells similar.
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.
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 dis-
similar 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.
43

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 atten-
tion 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.
44 HEALTHY SKIN
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 con-
sultant 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. 95-
0652. 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.

R
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 deliber-
ately with a walker. Once in bed, however, she has significant upper body weak-
ness and is unable to reposition herself.

Mabel eats 100 percent of three meals per day, but requires significant prompt-
ing 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.

46 HEALTHY SKIN
 SURVEY READINESS
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 47

Braden Scale for Predicting Pressure Sore Risk

Sensory Perception =2 Very limited

Moisture =1 Constantly moist
Activity =3 Needs assistance
Mobility =2 Very limited
Nutrition =2 Adequate
Friction and Shear =2 Potential problem

Total Braden Scale =12, Level of Risk = High Risk

Prevention:
Mabel currently has no wound or skin issues. Physical therapy/occu-
pational 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 supple-
ments 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: www.medline.com
2 Levels of Test Strips Small 1 Drop 1-800-MEDLINE (1-800-633-5463)
On Board Do Not Require Fingerstick
Quality Control Refrigeration Sample Size

• Make immediate warfarin dose changes

www.hemosense.com • Allows for more frequent testing

48 HEALTHY SKIN
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.

1-800-MEDLINE
www.medline.com
©2006 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Mundelein, IL 60060
50 HEALTHY SKIN
 SURVEY READINESS

Managing Dementia-
Related 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 51

 Managing Dementia-Related Incontinence continued
What interventions should be considered?
The following should be considered when devel-
oping 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.
• 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.
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).
52 HEALTHY SKIN
• 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 bath-
room is located or keeping the bathroom door
open at all times.
• Work with the family to select clothing the
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.
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
providing negative feedback or scolding them. Reference
1. Alzbrain.org.
Assessment and Management of
Urinary or Fecal Incontinence.
Available at: www.alzbrain.org
Accessed November 21, 2006.
 DO YOU KNOW IF YOUR
FACILITY IS SURVEY-READY?
Instead of wondering if your clinical team is in compliance with the updated
CMS Tag F315, take action with Medline’s Compass program. This compre-
hensive 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
To learn more about Compass, contact your
communication and documentation) Medline representative or call 1-800-MEDLINE.
www.medline.com
©2006 Medline Industries, Inc. Medline is a registered trade-
mark of Medline Industries, Inc.
The soothing
touch of aloe
in every wipe
Thousands of healthcare facilities already know the
secret – Aloetouch® wipes are simply the best choice.

Why? Because there’s aloe in every wipe. The pH–

balanced, hypoallergenic formula cleans, moisturizes
and conditions skin…all at the same time!

Available in a fresh, gender-neutral scent or unscented

for sensitive skin, the soft spunlace cloths are perfect
for any quick clean-up.

Aloetouch wipes from Medline – the right choice for

healthy skin.

1-800-MEDLINE www.medline.com
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.
 TREATMENT

PRESSURE
Relief
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 www.npuap.org.

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 55

 PRODUCT SPOTLIGHT

FOAM
DRESSINGS
Joyce Norman,
BSN, RN, ET/CWOCN, DAPWCA

56 HEALTHY SKIN
 TREATMENT

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 rea-
sonable 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 57


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
58 HEALTHY SKIN
A foam without adhesive is
a good choice for weepy
venous statis ulcers with
fragile periwound skin.
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 con-
sistent 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 neces-
sary 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 compro-
mised, 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

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
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.
foam before using under compression.) either feature silver coating on the
An example of foam use under com- face of the foam or silver throughout
pression is treatment of a venous stasis the foam.
ulcer.The foam absorbs the wound
drainage, allowing less frequent changes
of the compression dressing.
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. Joyce Norman has vast clinical experience
in many healthcare arenas, including acute
care and home care. She is a member of the
One innovative silicone-faced foam also
Wound, Ostomy and Continence Nurses
includes new polymer technology within
Society and the Association of Rehabilitation
the foam.As the exudate moves into
Nurses Society. Joyce is also a member of
the foam, the fluid is drawn and locked the Association for the Advancement of
into polymer. Even under compression, Wound Care and a Diplomat in the
there is no exudate movement back American Professional Wound Care
Association. Joyce has practiced the full
into the wound bed.
scope of ET/WOC nursing since 1985
and has taught and lectured extensively
Another recent technological advance is
throughout the country.
foam that contains silver to kill bacteria.
Because all wounds are considered
contaminated, an antimicrobial dressing
might be indicated.Antimicrobial foams
Improving Quality of Care Based on CMS Guidelines 59
 Hotline
Question
I have a resident who has a venous stasis ulcer on her
lower extremity with edema. Would an unna boot
be appropriate?
Answer
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 improve-
ment 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.
60 HEALTHY SKIN
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 applica-
tion. When the resident ambulates, their calf muscle pro-
duces 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.
 REGULAR FEATURES
Four-Layer Compression System
Delivers 35-45 mm Hg pressure on an ankle circumference After healing has taken place
of 18-25 cm Once the wound is closed, it is important to get the patient
in a therapeutic support stocking or garment. Remember,
A four-layer compression system, such as FourFlex or the disease is for life. The therapeutic support stocking or
Profore™, is a compression system and dressing all in garment will prevent further ulcerations from occurring.
one. There are four layers or wraps that together provide
adequate sustained compression.
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 Janet Jones is a board-
certified wound, ostomy
in a figure eight. The wrap is performed with a 50 and continence nurse. She
percent stretch. has extensive experience in
•The fourth layer is a self-adherent wrap. This layer long term care and home
care and has developed
is applied in a spiral at a 50 percent overlap and 50
wound prevention and
percent stretch. treatment programs for
many national healthcare
The entire compression system should be changed groups. She’s also ready to
take your call on Medline’s
after 48 hours and then every five to seven days, Educare Hotline!
depending on the amount of drainage.

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 61

Ankle Brachial Index (ABI) systolic pressure.
8. Slowly deflate the cuff, listening for the return of the
An ABI is the bedside comparison of the blood flow pres-
pulse. The point at which the arterial signal returns is
sures in the lower leg and those in the upper arm. This
recorded as the systolic ankle pressure.
screens residents for significant arterial flow problems to the
9. Repeat to obtain the ankle pressure over the other
extremities. An ABI will identify residents for whom com-
pedal pulse on the affected extremity. Use the higher
pression would not be appropriate. This test might not be
of the two values.
accurate for diabetics, whose vessels are often calcified, lead-
ing to a false positive.
To determine the ABI, divide the higher of the two ankle
pressures by the higher of the two brachial pressures. If only
Procedure
one ankle pressure could be obtained, use it.
1. Place resident in supine position five to 15 minutes
before test.
Ankle Pressure = ABI
2. Obtain brachial systolic pressure in each arm using a
Brachial Pressure
blood pressure cuff and doppler.
3. Record the highest brachial systolic pressure.
Interpretation of Ankle-Brachial Index
4. Place a cuff around the affected ankle.
0.95 - 1.3 Normal range
5. Apply acoustic gel over the dorsalis pedis or posterior
0.80 - 0.95 Compression is considered safe at
tibial pulse.
this level
6. Lightly touch the doppler probe (at an approximately
<0.8 - 0.5 Indicates mild to moderate arterial disease
45-degree angle) to the skin at either pulse location
<0.5 Severe arterial insufficiency
very lightly. Listen for a pulse.
>1.3 Abnormally high range
7. Inflate the cuff higher than the brachial

or

Dorsalis pedis pulse Posterior tibial pulse

= ABI

Brachial pulse

62 HEALTHY SKIN
 NEW Optimized features and value for the
5 Second Results
0.6 µL Sample Size Post Acute Care Professional
• 0.6 µL sample size
• Faster test time – only 5 seconds*
• Unique chemistry minimizes the effects of interfering agents, such as aspirin,
vitamin C, uric acid and acetaminophen, providing reliable, glucose-specific results
• Designed to start when sufficient sample is detected – minimizes repeat tests
and wasted strips
• Permits second drop if first sample is not adequate
• Accurate with hanging drop or touching application methods
• 450-test memory with time and date

Large Backlit Display
Makes test results
easier to see
Customized implementation to
meet your organization’s needs
• 24/7 Customer Care line
• Customized training
• Project management

For more information on Optium, contact your

Medline representative or call 1-800-MEDLINE
(1-800-633-5463).

Medline Industries, Inc.

One Medline Place, Mundelein, IL 60060
www.medline.com

©2006 Abbott. *Compared to previous Optium™ Blood Glucose Test Strips.

Documentation:
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.

64 HEALTHY SKIN

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 guid-
ance 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 suf-
fers. 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 compan-
ion) 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
www.amda.com.The guidelines
Improving Quality of Care Based on CMS Guidelines
SURVEY READINESS
themselves provide valuable This reference can be clipped
information for healthcare out and posted conveniently
providers treating residents for your staff.
who have or are at risk of
developing pressure ulcers. Karen Lou Kennedy-Evans was
the first Family Nurse Practitioner in
Listed on the following page Fort Wayne, Indiana. She worked at
are statements from the 1999 the Byron Health Center, a 500-bed
long term care facility in Fort Wayne,
companion guideline that can
Indiana, for 26 years. Her records in
be used in a number of ways.
the 1980s led her to the discovery of
Physicians, nurse practitioners
a pattern to terminal pressure ulcers,
and physician assistants can a type of ulcer that is now named
use them in progress notes the Kennedy Terminal Ulcer. She
when applicable. currently lives in Tucson, Arizona and
is the president of K.L. Kennedy, LLC.
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.
65
 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 67

 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

Oh,
current program to the next
level, we suggest the following
must-reads: this article — a great

Your
case study on what works and
why — and Safe Patient Handling

Aching
and Movement: A Practical
Guide for Health Care
Professionals. A tremendous

Back
resource, this book provides
detailed information on
“best practices in safe patient
handling and movement, the
By Julie Finley, BSN, RN
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

68 HEALTHY SKIN

W
When You Do the Math
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 resi-
dent! At one time she had as many
as three staff members on “light
duty.” Kim admits, “I was embar-
rassed. 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.”
Go to the Source:
Program Planning
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
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.
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 assis-
tance. By assessing each resident, the
team was able to determine equip-
ment criteria for each wing. Kim says,
“To this day, the team still does the
assessment for each resident.”
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
SPECIAL FEATURES
daily experience with lifting different
residents in a variety of situations,
they were the ideal staff to develop
the facility’s resident handling policy.
Program Implementation:
The Employees
Everyone in the facility was notified
that the staff was going “lift free” on
a certain date and a mandatory in-
service 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.”
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 any-
one 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.”
69
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 volun-
teered. Everyone could see how the
equipment worked!”
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
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
70 HEALTHY SKIN
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 some-
one 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 posi-
tions, such as admissions or restorative
specialist. Our minimal lift program
has eliminated light duty, improved
employee morale and given all care-
givers an everyday mindset of safety
for themselves.”
Julie Finley, BSN,
RN, has 26 years
of nursing experi-
ence 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
Movement: A Practical Guide for Health Care
Professionals. New York, NY: Springer
Publishing Company; 2006.
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 1-800-MEDLINE www.medline.com

 D
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,”
said Morgenstern.

72 HEALTHY SKIN
 CARING FOR YOURSELF

“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 73


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.
74 HEALTHY SKIN
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
• 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
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 connec-
tion. 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:
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 remember-
ing 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 won-
dering 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
O 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 75
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 your-
self 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
76 HEALTHY SKIN
house. Take away the obstacles to you get done, there are always 700
somebody helping you. Label the more right behind them. You are
insides of cabinets to help your never done, so how do you know
husband and kids know where when to stop? Now, on the other
things should go. Move the snacks hand, sitting one-on-one with your
to a lower shelf so the kids can spouse and spending an hour really
help themselves,” listening and finding out how their
Morgenstern suggests. day was – the return on investment
for that is huge.”
You don’t have to be perfect
“When people get very busy they Excerpts from pages 25 through 32 from
Never Check E-Mail In The Morning
tend to get very focused on the
reprinted with permission from Julie
small practical day-to-day stuff. Morgenstern. ©2005 Fireside Publishers.
You have to put what is truly most All rights reserved
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’
 J
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 compa-
nies, that are innovative, practical,
and easy to maintain. Since 1989,
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
Julie and her staff have worked with into popular one-hour PBS specials.
clients such as American Express, Julie and her teenage daughter Jessi
Microsoft, FedEx, Bear Sterns, co-authored ORGANIZING FROM
GlaxoSmithKline, the Miami Heat, THE INSIDE OUT FOR TEENS. Her
Julie Morgenstern
NBC-Newsroom, NYC Mayor’s Office, latest book, MAKING WORK, WORK,
Author, Speaker, Consultant
Sony Music, Medicare/Medicaid, is now available in paperback,
Viacom/MTV and Victoria’s Secret newly titled NEVER CHECK E-MAIL
IN THE MORNING.
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,

Improving Quality of Care Based on CMS Guidelines 77

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.

Franklincovey.com
For more information, or to
purchase the products listed,
please call 1-800-680-1812
or visit your local
FranklinCovey store.

78 HEALTHY SKIN
 SPECIAL FEATURES

?
What’s in a

NAME
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.

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

Improving Quality of Care Based on CMS Guidelines 79

 TOP Time Management Tips
By Lynne Ellis
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.

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?
Eliminate and Delegate Potential #1. Time Waster — Failure
Time Thiefs to prioritize and plan
• Interruptions It takes time, but people who do it
• Meetings actually accomplish the most in a day.
• Lack of organization This process includes doing a little
• Procrastination research before we jump into some-
• Funny emails thing. In the long run, a full under-
I love them but they tear me away standing of the issues saves time—even
from the important things. if it takes more time upfront.

The way we deal with others can also Let’s Make a Plan
have a big impact on our ability to get Now that we know how important it is
things done. For instance, some of us to clearly define our objectives and cre-
have trouble saying “no.” Some of us ate a plan of action, we can get started
don’t like to delegate so we wind up by evaluating how we currently use our
doing everything ourselves. time. If you’re spending too much time
on nonessential tasks and doing big
A rule of thumb projects at the last possible minute,
is to delegate planning and prioritizing will really
anything that help you get more done.
someone else Remember Too Much on Your
Plate…Eliminate and Delegate!
could do 80%
as well as you
could do it.

80 HEALTHY SKIN
TOP 10 TIPS
1. Plan your day Be sure to
ask yourself
2. Eliminate and Delegate as many time thiefs as possible if what you’re
doing right
3. Break large tasks into smaller ones so they’re not so daunting now is helping
you achieve
4. Use the 10-minute rule—spend just 10 minutes a day on your goals.
dreaded tasks (a suggestion from the Mayo Clinic)

5. Set aside a block of time each day for

paperwork and emails

6. Close your door and find other ways to eliminate distractions

7. When possible, say “no” to

extra tasks and interruptions
that don’t help you reach
your goals

8. Clear your workspace

of clutter—a messy desk
is not the sign of a
genius at work

9. Improve your concentration by

getting enough sleep and exercise

10. Take a break when you need one – this helps eliminate
stress and makes you more productive in the long run

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 81

SPECIAL FEATURES
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:
BRADEN SCALE DEMENTIA PEP
BUTTERFLIES DOCUMENTATION PRESSURE ULCER
CASE STUDY FOAM PSYCHOSOCIAL
CHRONIC WOUND INCONTINENCE RESEARCH
CMS MDRO SOLDIERS HOME
COLLAGEN MINIMAL LIFT UNNA BOOT
CRANBERRY OVERNIGHT BRIEF

82 HEALTHY SKIN
 FORMS & TOOLS

TABLE OF CONTENTS

Functional Incontinence 84

Incontinence Quality 86
Improvement/Quality
Assurance and Assessment

Policy & Procedure 88

Guidelines for Use 90

of Overnight Brief

Try Our Web Tools 92

Butterfly Watch 94

End of Life Plan 95

FORMS I TOOLS
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 83

FORMS & TOOLS

FUNCTIONAL INCONTINENCE
Residents with functional incontinence have
properly functioning bladders, but are inconti-
nent 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 HEALTHY SKIN
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 “Ultrasorbs has saved us over 20%
• Ideal for nighttime open-airing in product cost alone because of its
extraordinary absorbency and dryness.
Ultrasorbs underpads are available only from Medline; ask your We went from using an average of
representative for more information or call 1-800-MEDLINE. 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 | www.medline.com
©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.

Instructions:
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

Unit: Laurel Date: 10-11-2007 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 YES NO Color Code Brief Products
Green Small
Pull-ups YES NO White Medium
Purple Regular
Liners YES NO
Blue Large
Other: Tan X-Large

Resident/Room# Incontinent: Product Utilized Correct Product: Feedback related to Resolution

Yes/No Yes/No incorrect product

Room 120 B YES Brief-blue NO-Tan brief on Staff indicates that only Review distribution schedule
Resident: LK tan briefs on cart. with housekeeping and deter-
mine if enough supplies have
been ordered.

Room 122 A YES Brief-blue NO-Tan brief on Attending staff indicated Staff educational session
Resident: BH that the larger sizes completed, related that larger
“hold more urine.” sizes cause more leakage related
to poor fit, that each product
size of current brief have the
same absorbent factors.

Follow-up/Conclusion notes:

86 HEALTHY SKIN
 FORMS & TOOLS
Quality Assurance and Assessment Program
Facility Name
Incontinence Product Utilization

Unit: Date: 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 YES NO Color Code Brief Products
Green Small
Pull-ups YES NO White Medium
Purple Regular
Liners YES NO
Blue Large
Other: Tan X-Large

Resident/Room# Incontinent: Product Utilized Correct Product: Feedback related to Resolution

Yes/No Yes/No incorrect product

Follow-up/Conclusion notes:

Improving Quality of Care Based on CMS Guidelines 87

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 patient-
care 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.
88 HEALTHY SKIN
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 contamina-
tion 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),

• 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 side-
shields 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 protec-
tion 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
Improving Quality of Care Based on CMS Guidelines
Standard Precautions
POLICY & PROCEDURE
• 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 bleach-
containing 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 multidrug-
resistant 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.
89
FORMS & TOOLS
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

Goals
• 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 Document justification for brief use.
to qualify for a overnight brief 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 two-

hour 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.

90 HEALTHY SKIN
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 www.medline.com 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:

www.medline.com/woundcare Medline advanced skin and wound care

www.borun.medsch.ucla.edu The Anna and Harry Borun Center
Gerontological Research at UCLA
www.npuap.org National Pressure Ulcer Advisory Panel
www.apwca.com American Professional Wound
Care Association
www.ahrq.gov Agency for Healthcare Research and Quality
www.wocn.org Wound, Ostomy and Continence
Nurses Society
www.aawc1.com Association for the Advancement of
Wound Care
www.sawc.net Symposium on Advanced Wound Care
www.amda.com American Medical Directors Association

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

92 HEALTHY SKIN
 FORMS & TOOLS

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
1
using the Wound Care Product Selector
at www.medline.com/woundcare. The
program will ask questions about the
wound, such as depth, drainage and
periwound skin and suggest appropriate

2
dressings that meet current standards
of practice.

The Web site asks questions about the

condition of the wound.
3
Each question leads logically to the next,
following a decision-making algorithm
designed by CWOCNs and other
clinical experts.
4
With the information that is gathered, the
program suggests dressing options that are
consistent with standards of practice for
wounds with those characteristics.
5
Improving Quality of Care Based on CMS Guidelines 93
 BUTTERFLY WATCH

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.

94 HEALTHY SKIN
 LIFE CARE CENTER OF SARASOTA
END OF LIFE CARE PLAN
DATE REVIE PR OBLEMS GOALS
INITIATED W AND
DATE STRENGTHS
Is in the End of Resident will not undergo
Life stage unnecessary medical
related to 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.
Is expected to Will remain pain free and
have an comfortable as possible
increased
decline in
condition, which
is unavoidable
Will not exhibit signs or
symptoms of anxiety
APPR OACHES DISC GOAL ANALYSIS
Review Advance Directives Social
Continue to review resident preferences Services
Review effectiveness of current treatment Nursing
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 Nursing
Offer comfort foods and fluids of choice if Dietary
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 Nursing
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 All
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

Improving Quality of Care Based on CMS Guidelines

that is not alleviated
Provide bedside activities such as

95
FORMS & TOOLS

therapeutic massage, aroma-therapy, music

of choice, visual imagery, and document
96
LIFE CARE CENTER OF SARASOTA
END OF LIFE CARE PLAN
DATE REVIE PR OBLEMS GOALS APPR OACHES DISC GOAL ANALYSIS
INITIATED W AND
DATE STRENGTHS
Is in the End of Resident will not undergo Review Advance Directives Social

HEALTHY SKIN
Life stage unnecessary medical
related to 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.
Is expected to Will remain pain free and
have an comfortable as possible
increased
decline in
condition, which
is unavoidable
Will not exhibit signs or
symptoms of anxiety
Continue to review resident preferences Services
Review effectiveness of current treatment Nursing
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 Nursing
Offer comfort foods and fluids of choice if Dietary
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 Nursing
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 All
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

Resident and family
bereavement concerns
will be addressed
Resident will have a
peaceful death in the
facility in accordance with
expressed wishes.
RESIDENT ___________________________________________________________
________________________________
DATE OF ADMISSION __________________________________________________
____________________________________
Improving Quality of Care Based on CMS Guidelines
97
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 Nursing
Provide private time for relationships while Social
minimizing resident and family isolation Services
Chaplain services provided as desired
Elicit or confirm resident or surrogate goals Nursing
and values for life prolonging interventions. Social
Services
ROOM NUMBER
PHYSICIAN
XXX
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.
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 prima-
rily 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.

Q – DT: What are some of your concerns regarding the The future for us holds even more resident-centered care
use of your high-capacity brief? as we embrace culture change and train our staff using the
A – PQ: The overnight brief is extremely absorbent and LEAP* program, which is resident driven. The bowel and
can hold very large voids, which is fantastic. But our staff bladder team will continue to meet regularly and tackle
was misusing this brief, using them on all veterans instead problems as they come up.
of targeting those who really needed them. Subsequently,
costs went up. It became a compliance issue on all shifts. *LEAP is a program designed by Mather LifeWays to educate, empower
It might be partially due to poor performance on the part and retain staff by using a resident-centered approach.
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 com-
Word Search Answers
ponents: the veteran’s diagnosis (e.g., diabetes, CHF, tube
feedings) and medication regimen (e.g., diuretics, behav-
ioral 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

98 HEALTHY SKIN
We Have to
Hand it to
YOU...
FREE Ami Doll!
With the purchase of any three
Medline University courses.
Only $19.95 for all three!
Limited-time offer. Three courses must
be fee-based courses.

This is one offer too good to pass

up. Now you can take any of more
than 50 CEU credit courses online.
Choose any three and receive a
FREE Ami Doll.

Visit www.medlineuniversity.com to learn more.

MKT206318/LIT535/20M/MOR5