Legal Perils and Pitfalls of Wound Care, Part 4: Risk Assessments Protection Status
Risk Assessment

by Heidi H. Cross, MSN, RN, FNP-BC, CWON

Part 4 in a multi-part series looking at the basics of avoiding litigation as a health care provider. Read Part 1 Here, Part 2 Here, and Part 3 Here.

"Among the duties the defendants and their employees owed to Mr. JD but failed to perform was the duty to timely, accurately, and adequately assess his risk for skin breakdown and the development of a pressure ulcer."

Why Do a Risk Assessment for Pressure Ulcers?

When looking at medical charts from a legal perspective, one of the areas closely scrutinized is the risk assessment for skin breakdown and pressure ulcer development. Completing a pressure ulcer risk assessment is considered a standard of care. Was the patient adequately assessed, and was this done in a timely fashion? Was it repeated at regular intervals, with a change in condition, or on readmission? Do scores seem appropriate for the patient’s condition? Is there consistency among health practitioners? Were the results used to institute evidence-based and appropriate pressure ulcer prevention and treatment measures and care plans? Or do the results seem to simply languish in the chart? What are the standards of care related to this?

The most commonly used scale in the United States is the Braden Scale for Predicting Pressure Sore Risk.1 Developed in 1987 by Barbara Braden and Nancy Bergstrom, it has been extensively tested for reliability and validity. Used correctly and completed as designed, it is an excellent metric for the risk of skin breakdown.

What Do the Guidelines Say?

The 2014 National Pressure Ulcer Advisory Panel (NPUAP) Guidelines state, "Conduct a structured risk assessment as soon as possible (but within a maximum of eight hours after admission) to identify individuals at risk," "Repeat the risk assessment as often as required by the individual's acuity," and "Undertake a reassessment if there is any significant change in the individual's condition."2 The Guidelines also include recommendations about documentation and developing a plan.

What are the Pitfalls, and What Will Not Bode Well for the Defense?

  1. Not assessing pressure ulcer risk on admission. The NPUAP calls for risk assessment within eight hours, but this may at times be a little lofty. It should, however, be a goal we all endeavor to meet.
  2. Not repeating at regular intervals. How often the risk assessment should be repeated depends on the setting and the patient's condition. Usually, in the intensive care unit, it is conducted on every shift. On acute care units, generally every 24 hours is sufficient. In long-term care facilities, the Braden website suggests conducting risk assessment on admission, weekly for the first four weeks, and then quarterly.
  3. Inconsistencies among those completing the Braden Scale. What does that say about the staff and the facility if the scores vary widely? One day the patient may be a 12, only to be a 20 the next day, without any change in condition. Here are some of the possible reasons:
  • Inadequate staff training and familiarity. Be sure staff has been well trained, with periodic updates and in-services, and that scores are consistent from shift to shift.
  • Truncating or altering the Braden Scale. Reliability and validity were established using the scale in its entirety, exactly as published. Changes without reestablishing reliability and validity negate its effectiveness.
  • The Braden Score is completed by the night shift. I wonder how the night shift can truly know how well a patient eats and moves? Also, it is more difficult to assess sensory perception on a sleepy or sleeping patient.

So, what can go wrong relative to subscores?

  • Sensory perception: Often overlooked and overscored are diabetic and arterial patients, who inevitably have neuropathies. Also, how can a resident with paraplegia or quadriplegia score any more than a 2?
  • Moisture: It's not just incontinence. Moisture issues occur with diaphoresis, obesity, highly exudative wounds, weepy legs from venous insufficiency, etc.
  • Activity and mobility: Be sure to read the exact detail of the descriptions. Important: nursing scores on the Braden Scale should match physical therapy (PT) and occupational therapy (OT) assessments. If the Braden subscale is documented a 3 or 4, but PT and OT are documenting "max assist" in this area, there is a disconnect and will not reflect well on the facility.
  • Nutrition: Pay attention to the details, and score accordingly! If, for instance, meal intake is charted at < 50% or the patient has recently experienced unintended weight loss, low scores should be expected.
  • Friction/shear: Any bed-bound patient or one with a low mobility score will inevitably have a "problem" or a "potential problem."

Bringing It Full Circle

Conducting the Braden Scale is only the beginning and, unless translated into action, will amount only to busywork on the part of the nurses. Based on the subscores, an individualized and evidence-based care plan needs to be implemented, with interventions specifically targeted at needed areas. This is something that attorneys actively scrutinize!

1. Prevention Plus . Braden Scale for Predicting Pressure Sore Risk. Accessed December 12, 2018.
2. National Pressure Ulcer Advisory Panel (NPUAP). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington, DC: NPUAP; 2014. Available at http :// Accessed December 12, 2018.

About the Author
Heidi H. Cross, MSN, RN, FNP-BC, CWON, is a certified Wound and Ostomy Nurse in Syracuse, NY. She has extensive experience caring for wound and ostomy patients in acute care as well as in long term care facilities. Currently, she is employed by CNY Surgical Physicians consulting for nursing homes in the Syracuse area, and has served as an expert witness for plaintiff and defense attorneys.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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