Legal Perils and Pitfalls of Wound Care, Part 3: Turning and Positioning

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Turning and Positioning

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

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

"Among the duties the defendants and their employees owed to Mr. JD but failed to perform was the duty to turn and position him every two hours."

Essentials of Turn and Position Documentation

Failure to T&P (turn and position) is always part and parcel of a pressure ulcer lawsuit and a key element of a complaint related to pressure ulcers, as illustrated in the opening quotation. T&P documentation is a dominant focus in chart analysis and is usually one of the first things that an attorney and the expert witness look for. If T&P documentation is satisfactory, the defendant is likely to prevail; if not, then the plaintiff may have a pretty rock-solid case. But as I have opined in previous blogs, is there such a thing as perfect documentation? Alas...NO! (Or at least, rarely.)

So here are some suggestions:

  • Just like communication, consistency is key. If mention of T&P occurs only sporadically, especially in the nurse's notes, a judge and jury are definitely going to have the impression that it was not high on the staff's and the facility's priorities.
  • The need for T&P will be largely based on the mobility score (2 = very limited or 1 = completely immobile) and activity score (2 = chairfast or 1 = bedbound) of the Braden Scale. Of course, nothing trumps good nursing judgment of the patient's needs.
  • Be sure that T&P is part of the nursing care plan from day one based on the assessment and is part of the certified nursing assistant (CNA) care plan. CNAs are crucial team members, should be on board and educated about the importance of T&P, and should be involved in care plan development.
  • Be sure ALL team members are aware of and attuned to the patient's turning and mobility needs. This includes physical and occupational therapy, nutrition services, case management, and interdisciplinary care teams. And, oh yes, doctors!
  • Ideally, there should be a physician's order to T&P when the patient is at risk or has an existing pressure ulcer. If your facility has physician order sets, make turning orders part of them, as well as placing these orders on the Treatment Administration Record.
  • What is the ideal frequency of documenting T&P? There has to be a balance between expecting too much and accepting what may be perceived in a lawsuit as too little. A lot of it depends on a facility's documentation process and expectations. When I look at a chart, I look for what appears to be a "culture" of T&P. Free text nursing notes often tell a better story than check box flowsheets. There is also a danger to check box flowsheets because if boxes are left blank there will be strong presumption that those interventions did not take place.

What Do the Pressure Ulcer Guidelines Say About "Q2H"?

They don't! The 2014 National Pressure Ulcer Advisory Panel does not recommend a frequency but suggests that we "consider the pressure redistribution surface in use" and also "tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort." 1 Similarly, the Wound, Ostomy and Continence Nurse Pressure Ulcer guidelines state, "schedule regular repositioning and turning for bedbound and chairbound individuals."2 The TURN study by Nancy Bergstrom and associates found no difference in pressure ulcer development between "those at moderate and high risk of developing Pressure Ulcers turned at 2-, 3-, or 4-hour intervals...using high-density foam mattresses."3 There is nothing evidence-based or magic about the two hours of "Q2H" turning!

What About Patients’ Non-adherence or Refusals?

If patients refuse T&P efforts, that is their right (of course, it also is their right to sue if they subsequently develop a pressure ulcer). Documentation of refusals becomes crucial!

Document:

  • The reason that patients refuse T&P. Use of exact quotes from patients can be very effective. Is it because of pain and the need for a reassessment of their pain regimen? Are they close to end of life and don't wish to be disturbed? Maybe they just don't understand the dangers of immobility and the risk for skin breakdown. Sometimes it may be a control issue, understandable when everything else in their life seems out of their own control.
  • What actions you took as a result and the education you provided about the need for adherence.
  • Patients' reactions to the education. This demonstrates patients' understanding and, implicitly, patients' consent, assuming cognition is intact.
  • Be sure to involve all staff in reinforcing the need, so patients are hearing it from multiple providers, and of course educate and involve the family.

Next up? That all important Risk Assessment...

References
1. National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. 2014. Available at https://www.npuap.org. Accessed November12, 2018.
2. Wound, Ostomy, and Continence Nurse Society (WOCN Society). Guideline for Prevention and Management of Pressure Ulcers. WOCN clinical practice guideline series no. 2. Glenview, IL: WOCN Society; 2016.
3. Bergstrom N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Turning for ulcer reduction: a multisite randomized clinical trial in nursing homes. J Am Geriatr Soc. 2013;61(10):1705–13.

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.

Comments

I don't believe we still have these problems and why preventing pressure injuries is so hard when it is so simple. If a patient cannot reposition themselves then they are 'at risk'. Just teach the sicker the patient is the quicker a injury can occur.
Nutrition incontinence and other risk factors are important but the urgency of placing the patient on an alternating pressure air mattress is essential with skin checks and still regular turning.
Nurses are run off their feet so keep it simple and achievable. Read Catherine Sharps Work and Brenda Ramstadius they have been saying this for years. Come on its now 2018.

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