Avoiding Pressure Injuries in Long-Term Care

Pressure injuries, often referred to as pressure ulcers, pressure wounds, or bedsores, present a significant and prevailing concern in long-term care settings, particularly in skilled nursing facilities. These injuries can have profound effects on quality of life and overall well-being for patients, making it imperative for health care professionals to discern between unavoidable and avoidable pressure injuries.

Pressure injuries pose a significant challenge in skilled nursing facilities, where patients often have limited mobility and underlying health conditions that predispose them to skin breakdown. According to one study, pressure injuries are prevalent in skilled nursing facilities, affecting a substantial proportion of long-term care residents.¹ These facilities often care for patients with complex medical needs and those with chronic conditions, such as diabetes or immobility, which elevate the risk of pressure injuries.²

Upon admission to skilled nursing facilities, a thorough assessment of the patient's skin condition is paramount. It is also critical to assess their risk factors for developing or progressing injuries. The initial evaluation should include a meticulous inspection for any existing pressure injuries or areas of compromised skin integrity. Identification and documentation of pressure injuries upon admission allows health care professionals to initiate timely interventions, prevent further deterioration, and guide appropriate pressure injury management strategies.³

It is also important to gather a complete patient history, including the history of their pressure injuries and risk factors. Although the Braden Scale is the most widely used pressure injury risk assessment tool in health care settings and specifically in skilled nursing facilities, it has significant limitations. Barbara Braden has acknowledged the assessment of risk should not be limited to the four corners of the scale, but rather include a nurse’s clinical judgment.⁴ For example, the scale does not account for current or past pressure injuries, which automatically confer high-risk status. Although a score of 1 in the first five subscales indicates high risk, the tool lacks this interpretive guidance. Thus, nurses may underestimate risk if strictly adhering to the Braden Scale score. One piece of research shows the scale has low predictive validity, particularly for older long-term care residents.⁵ While a useful starting point, the Braden Scale should be supplemented with comprehensive skin checks, clinical expertise, and consideration of additional risk factors. Nurses and other providers should not depend solely on the Braden Scale score to determine prevention plans. Ongoing refinement of risk assessment methods is needed to improve early identification of patients in nursing homes who are vulnerable to pressure injuries.⁶

Once the patient’s level of risk has been determined, a comprehensive care plan must be developed and implemented. These care plans should address each patient's specific needs, including repositioning schedules, specialized support surfaces, proper nutrition, and meticulous skin care. By implementing preventive measures early on, health care providers can significantly reduce the incidence of pressure injuries and improve patient outcomes.⁷ It is important to remember that initial care plans are not stagnant; rather, they require adjustments based on changes in the patient’s condition, both in terms of their skin and overall.

Not all pressure injuries are avoidable. As such, the difference between avoidable and unavoidable pressure injuries is essential to understand. Avoidable pressure injuries are described as pressure injuries that develop when a health care provider fails to do one or more of the following: consistently provide routine pressure injury prevention, properly assess a person's clinical condition and pressure injury risk factors, develop and implement an individualized care plan for pressure injury prevention, provide appropriate pressure-redistribution surfaces, or reposition and mobilize a person appropriately for his or her level of risk.⁸ The US Centers for Medicare & Medicaid Services (CMS) has described how avoidable pressure injuries can represent substandard care by health care providers, as they are usually considered preventable with proper patient assessment, care planning, and implementation.

Unavoidable pressure injuries are injuries that develop despite proper and documented pressure injury prevention and treatment.⁹ These are not likely avoidable or the result of poor care; they can develop due to clinical conditions that impair perfusion and oxygenation or reduce the adequacy of nutrition, causing skin failure. According to CMS, documentation must clearly show that clinicians have consistently provided comprehensive pressure injury prevention and treatment to demonstrate that a pressure injury was unavoidable (Table 1).

Table 1. Common Differences between Avoidable and Unavoidable Pressure Injury

In summary, avoidable pressure injuries represent deficient care, whereas unavoidable pressure injuries can develop despite proper prevention and treatment due to patient-specific clinical factors. Authorities such as CMS provide guidelines to define and document both types.

To avoid the development and progression of pressure injuries, maintaining appropriate pressure offloading practices is crucial. Health care facilities, including skilled nursing facilities, must adhere to well-defined standards of care to minimize the risk of pressure injuries among their residents. This section highlights the importance of using specialized support surfaces and implementing regular turning and repositioning protocols, emphasizing the significance of maintaining a schedule that ensures patients are turned and repositioned at least every 2 hours when needed.

The National Pressure Injury Advisory Panel (NPIAP) developed and maintains the support surface classification system for Groups 1, 2, and 3. Specifically, the NPIAP Support Surface Standards Initiative (S3I) committee oversaw the creation of this categorization based on guidelines from the European Pressure Ulcer Advisory Panel and input from clinicians, researchers, manufacturers, and other experts.¹⁰

The NPIAP first introduced the support surface classification system in 2007 and has continued to update and refine the definitions and criteria for Groups 1, 2, and 3 as technology and evidence evolves. The most recent 2019 version provides the current standard framework for categorizing support surfaces in pressure injury prevention and treatment (Table 2).¹¹

Table 2. The National Pressure Injury Advisory Panel Support Surface Classification (2019)

This grouping system helps categorize support surfaces by their key features, level of pressure redistribution, and appropriateness for patients with varying degrees of pressure injury risk. Health care facilities use this classification to ensure patients receive adequate pressure-offloading interventions tailored to their needs.¹²

In addition to using specialized support surfaces, consistent turning and repositioning of patients are fundamental practices in pressure offloading. Regularly changing a patient's position helps alleviate pressure on specific areas and promotes blood circulation to vulnerable tissues. The benefits of turning and repositioning are as follows:

• Pressure redistribution: Turning and repositioning allow pressure to be redistributed across different areas of the body, reducing the concentration of force on any one spot.¹³
• Skin integrity maintenance: Frequent changes in position help prevent the development of pressure sores and promote skin integrity.¹⁴
• Comfort and well-being: Patients who are regularly turned and repositioned experience greater comfort and are less likely to suffer from discomfort or pain associated with prolonged immobility.¹⁵
• Respiratory and circulatory benefits: Repositioning also supports proper lung expansion and blood flow, reducing the risk of respiratory complications and circulatory issues.¹⁶

When caring for patients at high risk for pressure injuries, it is vital to individualize pressure offloading based on each patient's specific needs. The consistency of turning and repositioning is essential for optimal pressure offloading by turning residents 30 degrees off their sacrum while avoiding other bony areas such as the trochanter. Establishing a turning and repositioning schedule is crucial, with the goal of repositioning patients in accordance with their tissue tolerance rather than every 2 hours. Health care facilities must ensure that nursing staff are educated and trained on the need to adhere to this schedule.¹⁷

The established standard of care is to turn and reposition patients every 2 hours. However, current scientific evidence does not strongly validate this rigid approach. Best practices may differ from standards of care, which represent what similar providers would reasonably do in a given situation. For some patients, frequent turning may cause pain, disrupt sleep, or otherwise negatively impact health. Clinicians should conduct thorough skin assessments, evaluate pressure points, assess perfusion, and consider the patient's comfort. They can then develop an individualized care regimen that includes the ideal repositioning schedule and uses preventive technologies, such as pressure-redistribution surfaces. While standards provide guidance, optimal pressure injury prevention requires customizing offloading to each patient’s clinical presentation, risk factors, and preferences.¹⁸

Often it is the case that a patient in the state of declining health, especially in terms of their chronic comorbid conditions, can experience an acceleration of their decline either due to patient-related factors or caregiving deficits, which then precipitates further deterioration. It is critical to prevent this decline from occurring and to recognize the potential impact of pressure injuries on mental health and overall well-being. Patients with pressure injuries, especially those experiencing chronic pain and limited mobility, may be more susceptible to developing depression.¹⁹ The physical and emotional burden of a pressure injury can lead to feelings of helplessness, isolation, and frustration.²⁰

Furthermore, pressure injuries can exacerbate existing chronic conditions, leading to a decline in overall health and well-being.²¹ More often the impact of pressure injuries on patients experiencing failure to thrive is a factual although in some situations of avoidable pressure injuries these conditions can be contributing factors in the development and ability to recover. Early detection of pressure injuries and their potential emotional consequences allows for timely intervention. Implementing comprehensive care plans that address not only pressure injury healing but also mental health and psychosocial support can improve patient outcomes.²²

Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD¹

Affiliations:

¹Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA

Disclosure:

The author reports that he serves as faculty for AMDA’s CMD program and has served in the past as an expert for both plaintiff and defense in cases involving Pressure Injuries in LTC.

Address correspondence to:

Richard G. Stefanacci, DO, MGHm MBA, AGSF, CMD

Email: Richard.Stefanacci@Jefferson.edu

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