Pressure Ulcers in Nursing Homes: What They Signal About Staffing

When searching for a nursing home, the presence of pressure ulcers, often called bedsores, is a red flag. These injuries develop when someone remains in one position too long, cutting off blood supply to the skin. They often indicate understaffing, as prevention requires consistent care. Understanding the implications of pressure ulcers can guide you in evaluating a nursing home's care quality.

What Are Pressure Ulcers?

Pressure ulcers are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. Common areas where they develop include the tailbone, hips, heels, and elbows. These areas are more susceptible because they are where the body's weight commonly rests when someone is lying down or sitting for extended periods.

Prevention in nursing homes involves basic care measures: regular repositioning of residents, using pressure-relieving surfaces, ensuring proper nutrition and hydration, and frequent skin inspections. Consistent pressure on a single area without relief can diminish blood supply and ultimately cause tissue death. Therefore, the presence of pressure ulcers suggests that these preventative measures are not being adequately implemented.

Connection Between Staffing and Pressure Ulcers

Preventing pressure ulcers is a time-intensive task that largely depends on having sufficient nursing staff. Regular repositioning and skin inspections require direct caregiver involvement. When a nursing home is understaffed, these basic care tasks can be neglected, leading to the development of pressure ulcers.

Staffing levels are crucial. The national average total nurse staffing is 3.86 hours per resident per day, with registered nurse staffing at 0.69 hours. An important aspect of evaluating a facility's potential to deliver adequate care is to look beyond these averages to see what services are offered during weekends or overnight, times that tend to have fewer staff on hand.

If you notice signs of bedsores on your loved one, it's essential to address it immediately. Ask the nursing home about their staffing levels and whether they adhere to the recommended staffing standards. Be vigilant of the work environment, as a high turnover rate could imply instability in a facility's staffing pattern.

Common Locations for Pressure Ulcers

Understanding where pressure ulcers typically occur is crucial in monitoring and preventing them effectively. The most common sites are bony areas like the tailbone, hips, heels, and elbows. These locations are at increased risk because the skin is thinner and has less cushioning from fat and muscle, resulting in higher susceptibility to damage from pressure.

In residents who are bedridden or in wheelchairs for prolonged periods, other vulnerable areas can include the back of the head, shoulders, lower back, and other areas that may come into contact with wheelchairs or bedding. Being aware of these hot spots can aid in early detection and the possible prevention of more severe wounds. Regular examination of these sites can lead to prompt intervention as necessary.

CMS Measures and Health Inspections

The Centers for Medicare & Medicaid Services (CMS) publishes a long-stay pressure ulcer quality measure as part of their nursing home data. Apart from quality measures, pressure ulcer care is a recognizable category in health inspections. This means that inspectors pay close attention to the presence and treatment of these ulcers during evaluations.

In the ElderGrade database, you can find information on health inspection citations, which include documentation on care deficiencies related to pressure ulcers. Of our 418,344 health-inspection citations, 23,004 were scored as actual harm or immediate jeopardy. This data is crucial for evaluating the safety and care standards of a facility. Facilities must adhere to inspection protocols which include demonstrating their procedures to prevent and manage these ulcers.

You can use our guide on how to read a nursing home inspection report to understand more about pressure ulcer documentation in these citations: Reading an Inspection Report.

Practical Questions to Ask

Facing this situation can be challenging. To ensure your loved one receives appropriate care, you should ask the right questions:

• How often is repositioning documented for residents? Consistent repositioning is critical in preventing pressure ulcers, and documentation ensures accountability.
• What is the current nursing staff-to-resident ratio? Adequate ratios are essential in providing each resident with the attention they need, especially concerning preventive care measures.
• What procedures are in place to prevent pressure ulcers? Knowing the steps taken can give you insight into a facility's standard operating procedures and their adherence to care standards.
• Can I see the wound care plan in writing? Documentation of a care plan is crucial for transparency and ensuring that your loved one receives the care they require.
• What is the process for escalating care issues that are not resolved? Having a clear escalation protocol ensures that there is a path to address concerns that might otherwise be overlooked or inadequately addressed.

These questions can help you gauge the quality of care a facility provides and decide if it's the right environment for your parent.

Common Mistakes to Avoid

One of the most common mistakes families make is overlooking the importance of staffing levels. Understaffing can affect all aspects of care, not just the prevention of pressure ulcers. Be sure to review the facility’s staffing details carefully. Examine weekend and night staff levels, which are critical times for ensuring ongoing monitoring and care.

Families may also assume that pressure ulcers are merely a consequence of advanced age or illness. While these factors can contribute, the primary cause in a nursing home is usually insufficient care. Highlighting this issue with facility management and monitoring their response is critical. Use resources like ElderGrade's guide to understanding nursing home staffing to delve deeper into what different staff numbers mean: Understanding Staffing Numbers.

Escalating Concerns

If you discover a worsening pressure ulcer, take action swiftly. This includes photographing the wound and noting dates, requesting written wound care plans, and ensuring that repositioning is regularly documented. These steps serve as a record and an accountability tool to ensure that care procedures are adhered to diligently.

If the facility does not handle the situation appropriately, contacting the state’s nursing home ombudsman can be a vital step. They serve as an advocate for residents and can assist in resolving ongoing care issues. Escalation ensures that you are not alone in advocating for proper care. For additional insights on residents' rights, refer to our guide: Residents' Rights in Nursing Homes.

Using ElderGrade for Choosing a Facility

To choose the right facility for your parent, utilize resources like ElderGrade to compare nursing homes and understand ownership patterns, staffing, and inspection performance. Our nursing home search tool allows you to examine various facilities’ ratings. Identifying top facilities can be a good starting step; consider exploring our list of best-graded homes. Investigate further into homes you are interested in, especially those listed in our watchlist of flagged homes for facilities with known deficiencies, to understand potential risks.

Furthermore, understanding the facility’s history can provide context about their operations. Utilize ElderGrade’s guide on nursing home ownership to understand more about ownership, as changes in ownership can sometimes correlate with changes in care standards.

The bottom line

Pressure ulcers in nursing homes are a significant indicator of staffing quality and care standards. By scrutinizing facilities’ preventive measures and asking pointed questions about staffing and wound care, you can make a more informed decision for your parent's nursing home care.

Where these figures come from

Every number in this article that describes American nursing homes comes from the CMS Provider Data Catalog, the same public federal files behind Medicare's Care Compare. You can see exactly which datasets we use, and how current they are, on our data sources page. Nothing here is medical, legal or financial advice — rules differ by state and change over time, so verify anything that affects a decision with the facility, your state survey agency, your Long-Term Care Ombudsman, or a qualified professional.