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Good Policy to Perform Braden Scale After Residents Develop a Pressure Ulcer?
Background
A skilled nursing facility (SNF) had a policy that included the assessment of pressure ulcer risk through the use of serial Braden Scales upon residents’ admission and then weekly for 4 weeks. In addition, the facility required the nursing staff to perform Braden Scales weekly for 4 weeks if a resident developed a pressure ulcer.
The Case
A 75-year-old woman was transferred to the SNF following a cerebrovascular accident. As a consequence of her stroke, the resident had right-sided paralysis and dysphagia requiring a pureed diet with thickened liquids. She was frequently incontinent of bowel and bladder.
The admitting nurse performed a Braden Scale and recorded the following:
- Sensory perception-4, no impairment
- Moisture-3, occasionally moist
- Activity-2, chair-fast
- Mobility-3, slightly limited
- Nutrition-3, adequate
- Friction/shear-2, potential problem
The Braden Scale score calculated by the nurse was 17, corresponding with a mild risk of pressure ulceration. Because of the high score (low risk), no preventative interventions were implemented.
Second Look
Upon review of the score calculation, several errors were noted, including failure to identify the resident’s inability to respond to pressure-related discomfort due to her right-sided paralysis. Although she was intact on the left side, she was unable to perceive pressure on her right side or to reduce the pressure independently. The degree of incontinence of both bowel and bladder (moisture) was greater (2), and her mobility was more limited (2) than identified by the nurse. Dysphagia had a more significant affect on her nutrition (2). The need to boost the resident up in bed increased her risk of friction and shear (1). The actual Braden Scale should have been 11, placing the resident at high risk and requiring the implementation of pressure-reducing support surfaces, skin care for incontinence, turning and repositioning, and close monitoring of nutrition.
The three subsequent Braden Scale scores were identical to the initial score that incorrectly identified the resident as low risk for wound development.
A pressure ulcer was subsequently discovered several weeks after the resident’s admission. The staff continued to score the resident as a low-risk individual despite the presence of a pressure ulcer, as the Braden Scale does not ask the nurse to identify the presence of an actual wound or if there is a history of a healed lesion.
Alternative Course
Rather than requiring the nursing staff to complete a Braden Scale for pressure ulcer risk, the development of a pressure ulcer in a resident previously regarded as being at low risk should prompt the following interventions:
- A QAPI project that focuses on residents who have developed wounds, and reviews the Braden Scale scores for those residents to determine if miscalculations occurred;
- Using a resident who was incorrectly regarded as being at low risk for the development of pressure ulcers, conduct an in-service education program that asks the nursing staff to calculate the score, provide an explanation of the six risk factors of the Braden Scale, then ask the staff to recalculate the score based on the new learning that occurred;
- Rather than requiring four additional Braden Scale calculations, implement a policy that the interdisciplinary team reconvenes to review the care plan for actual pressure ulceration.
Risk assessment tools such as the Braden Scale can be useful in caring for complex long-term care residents, however staff must go beyond the completion of the scale and address the interventions necessary to prevent and heal wounds.
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Ilene Warner-Maron, PhD, RN-BC, CWCN, CALA, NHA, FCPP, has been practicing nursing for 33 years, specializing in the care of geriatric patients. Dr. Warner-Maron is the president of the Institute for Continuing Education and Research, providing educational programs for individuals seeking licensure in nursing home administration.
