Skin Observation Protocols

Table of Contents

Assumptions	Page 2
Observation Not Required	Page 4
No Highest Risk Indicators	Page 4
Skin Problem over Pressure Points present and treatment is being done by a non-professional.	Page 4
Client reports that they have a pressure ulcer and there is an appropriate treatment plan in place and client’s skin has been seen by the health care professional responsible for treatment within the last 7 days	Page 4
Cognitively intact client who meets the highest risk indicators declines skin observation and CM doesn’t know if there is a problem	Page 4
Observation Required	Page 5
Protocol not triggered but skin problems related to pressure ulcers identified by client or caregiver, or noticed by CM within the course of the visit/assessment	Page 5
Highest Risk Indicators present and the protocol triggered	Page 5
The skin observation may be delayed if:	Page 6
The situation is unsafe…	Page 6
Unable to visualize skin because of…	Page 6
The cognitively intact client declines observation of skin over pressure points and there is evidence of negative skin outcome…	Page 6
Client refuses once and is cognitively impaired	Page 7
Client consistently refuses and is cognitively impaired	Page 7
Client meets highest risk indicators but observation not completed due to culture, gender, assessor’s skill or supervisor concerns	Page 7
Highest Risk Indicators of Skin Breakdown over Pressure Points	Page 8

Assumptions

The protocols are based on the following assumptions:

1. It is our responsibility to assess the client’s care needs which include health care issues. Addressing identified issues in the client’s service plan is integral to a comprehensive plan of care. The definition below is offered here because it incorporates many of the functions of caregivers in support of clients. It is not intended to be a definition of case management.

Health Insurance Portability and Accountability Act (HIPAA) definition of health care:

“Health care” means care, services or supplies related to the health of an individual, including, but not limited to: preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental condition, or functional status, of an individual or that affect the structure or function of the body; and sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription.”

2. Skin observations do not need to be done for every client. It is estimated that the protocols will apply to 10-20% of the caseload, those clients whose assessments are positive for the highest risk indicators. The number of clients who require direct observation will be reduced further by those clients who already have an appropriate plan in place.

3. Current HCS and AAA (Social Workers and Nurses) will continue to perform assessment functions, including skin observation.

4. Assessing the skin has always been an expectation of case managers as part of a comprehensive assessment, but we largely relied on self-reporting and protocols were not in place.

5. There are many indicators that place a person at risk for skin breakdown over pressure points. Out of these the indicators that place a person at highest risk will trigger the protocols for skin observation.

6. Case Managers are not expected to diagnose, but observe, identify, document and make appropriate referrals according to protocols.

7. It is expected that there will be a reasonable effort to schedule the home visit when there will be a third party present. However, if the assessment triggers the skin observation protocol, the case manager is expected to facilitate the observation if the protocol indicates the need.

8. HCS and Aging Network Case Managers will not continue authorization of services and payment, but will attempt to offer alternatives, when services cannot be delivered according to the plan of care or services are not being adequately delivered due to caregiver issues or client choice.

9. It is recognized that even with a good service plan in place, the potential for a negative outcome exists. The protocol provides policy direction for definition of case management practice related to skin observation over pressure points.

10. Nursing services will be used by HCS/DDD/AAA/ CMs according to the AAA Nursing Services.

11. Training is an important component in decreasing the risk of skin breakdown over pressure points for our clients. This includes training for caregivers and case managers as well as educational materials for clients and their families.

Skin Observation Protocols

(Please Note: Text in italics are comments that have been received in preliminary reviews)

Observation Not Required

1) No Highest Risk Indicators

i) No skin risks or problems identified

(a) Document

2) Skin Problem over Pressure Points present and treatment is being done by a non-professional.

i) When possible, on the same day, the CM should:

(a) Review the treatment being done with the caregiver. Treatment may not always be feasible when CM is present.

(b) Document what is being done.

(c) Verify that caregiver is checking all pressure points.

(d) Make referral to HCS/AAA nursing expertise services.

(e) Within 5 working days, give caregiver instructional materials (pictures or text) about pressure points. Who makes sure caregiver has had appropriate instructional (or available ) materials?

(f) Make any necessary changes to the service plan.

(g) Document CM activities

3) client reports that they have a pressure ulcer and there is an appropriate treatment plan in place AND CLIENT’S skin has been seen by the Health Care Professional responsible for TREATMENT WITHIN the last 7 days.

i) CM will verify that there is a treatment plan in place for skin problem over pressure point(s).

ii) As soon as possible, but not to exceed 5 working days, communicate with the Health Care Professional to verify that all pressure points are being checked. Request to be notified when client is discharged from care for pressure ulcers. At that time, the CM consults with nursing services.

4) The cognitively intact client who meets the highest risk indicators declines observation of skin over pressure points and CM does not know if there is a problem

i) Probe for reasons, suggest appropriate alternatives and document and

ii) Make a referral for HCS/AAA nurse to follow up and document or

iii) Contact client’s primary care provider as soon as possible, discuss skin concerns and document or

iv) Advise the client of skin care issues, educate and document

v) Do not complete skin observation, ask the client to sign a refusal form, document and discuss with supervisor.

Observation required

1)Protocol not triggered but skin problems related to pressure ulcers identified- client or caregiver reports, or CM notices within the course of the visit/assessment

i)Document what is reported or observed

ii)i)Address skin problem in Service plan

iii)i)Follow protocols as if the client met the highest risk indicators.

2)1) Highest Risk indicators present and the protocol triggered:

a) Steps to complete the observation

i) If you know in advance that there is a likelihood that you will need to observe the client’s skin, arrange to have a third party present, most appropriate is probably the caregiver. Involve the client in determining who this third party should be when possible.

ii) Explain to the client that you would like to check their skin over the pressure points and ask permission.

iii) Tell the client where the pressure points are

iv) Look at both back of the head, both ears, shoulder blades, elbows, insides of the knees, “seat” bones, tailbone area, hips, sides of ankles and both heels.

v) If the client needs to undress partially, help them or have the caregiver help them as needed. Be sure that there is privacy for the client.

vi) Observe for specific conditions- skin intact, persistent redness, abrasion, blister, shallow crater, deep crater, etc. as directed on the CA.

vii) If no skin problem is observed, document and include a prevention plan in the service plan

viii) If a skin problem is observed

(1) Determine if there are any health professionals involved with treatment of the client’s skin problem or if any health professionals are aware of the problem.

(2) Within 2 working days, initiate and maintain contact with any health professional involved with treatment of the client’s skin problem.

(3) Within 2 working days, make a referral to the HCS/AAA nurse or home health or primary physician.

(4) Contact family rep if no health professionals involved or client is refusing treatment or HCP is not treating.

(5) Document all steps taken (needs more detail)

The skin observation may be delayed if:

1) The situation is unsafe and the case manager’s personal safety may be at risk. There may be threatening animals. The client may exhibit sexually inappropriate behavior or threatening violence. Need 3^rd party present

i)Follow normal CM procedures, discuss with supervisor and reschedule skin observation

ii)i)Document

iii)ii) Discuss with supervisor within one working day and follow usual CM response times. (See LTC Program Manual Chapter 3- Assessment) Reschedule the observation within 2 working days.

2) Unable to visualize skin because of soiling or unhygienic conditions and no caregiver present to assist or the client’s physical condition makes it physically very difficult to observe skin (immobile, needs transfer or positioning assistance, client is in pain)

i) Anticipate these barriers as much as possible and make arrangements prior to the visit to have a caregiver, assistant, or family member present to help client.

ii) Document that you have made arrangements or attempted to make arrangements

iii) Call and discuss with your supervisor and reschedule skin observation within 2 working days.

iv) Document

v) Follow usual CM timeframes. See LTC Program Manual Chapter 3- Assessment

3) The cognitively intact client declines observation of skin over pressure points and there is evidence of negative skin outcome.

i) If emergency, call 911

ii) Someone else looks- for instance- the caregiver, a family member or person that client feels comfortable with, home health nurse, AAA nurse, primary care provider within 2 calendar days. CM to verify and document that observation was done.

iii) Collect collateral info re: skin problems over pressure points from health care providers, caregiver, family or other involved parties.

iv) Educate caregiver by going over section of the service plan that describes skin care over pressure points. - 5 working days.

v) Refer to APS as appropriate, make referral same day as visit

vi) Referral to RN for same day visit. There is a concern that the system does not support this time frame.

vii) Explore other appropriate services such as residential placement, different caregiver, community clinic, other community-based resources (discuss with supervisor).

viii) All involved parties come to consensus about when to terminate services.

ix) Document all steps taken

x) Termination of personal care and ancillary services when continuation of these services put the client at risk. Client may be kept open to CM services. Activities such as daily welfare checks by CM, family or other community members such as police, EMTs, mail carriers or other identified gatekeepers.

4) Client refuses once and is cognitively impaired

i) Using good interview and assessment techniques, try requesting permission more than once.

ii) Be sure that the client understands as much as possible what you are requesting.

iii) Document what you have done

5) Client consistently refuses, is cognitively impaired, meets highest risk indicators and we don’t know about skin problems. Refuses to allow observation, has an unreliable provider and won’t let anyone else in, and /or refuses services related to skin integrity over pressure points.

i) Initiate Guardianship fast track with AAG involvement (services are not terminated). AAA’s refer to APS for fast track guardianship (services are not terminated) and;

ii) APS referral and;

iii) Networking /refer to other services

(1) Offer alternative services or;

(2) Offer a different provider or;

(3) Residential placement or;

(4) Change in way services are delivered and;

iv) Probe to understand basis of refusal and

v) Continue to keep open to CM services as funded by SCSA and OAA, but terminate other services and monitor for crisis and

vi) Welfare checks, alert neighbor, police, CM and/or

vii) 911, ER or possible IDT, or MHPs, if appropriate.

6) Client meets highest risk indicators but observation not completed due to culture, gender, assessor’s skill or supervisor concerns.

i) CM discusses with supervisor and find reasonable solution. A reasonable solution is defined as timely, respecting of personal and professional boundaries, and has an end result that someone observes client’s skin and documents what was done for client or

ii) Discuss with supervisor as soon as it is discovered that client meets highest risk indicators and

iii) Supervisor or designee provide training to the CM within 30 days (time frame is unrealistic as per # of days as training or trainer for questioned issues may not be readily available. Assuming training can be done by qualified on site staff?, supervisor? program manager? formal training? group or individual?) or

iv) CM refer to nurse after consultation with supervisor or

v) Supervisor reassign case and

vi) Skin observation completed within 2 working days and

vii) Supervisor documents steps taken

Appendix B

HIGHEST RISK INDICATORS FOR SKIN BREAKDOWN OVER PRESSURE POINTS

I. Stand Alone Items

• Current Pressure Ulcer
• Quadriplegia
• Paraplegia
• Total Dependence in Bed Mobility
• Comatose or Persistent Vegetative State
• History of pressure ulcer within one year

II.Combination of Elements

1. Bedfast and/or chairfast, and cognition problems.
2. Bedfast and/or chairfast, and incontinent of bladder or bowel.
3. Hemiplegia, and cognition problems, and incontinent of bladder or bowel.
4. Bedfast and /or chairfast, and Insulin Dependent Diabetes Mellitus (IDDM)

Bladder incontinence is defined as multiple daily episodes of the individual being wet, even with the use of appliances or programs used to manage this.

Bowel incontinence is defined as inadequate control all or almost all of the time, even with the use of appliances or programs to manage this.

Note: Cognitive impairment is defined by a score of 3 or higher on the Cognitive Performance Scale.