By Mary Ellen Posthauer RDN, CD, LD, FAND

Since we are fast approaching the deadline for the national elections, I decided to join the fray and campaign for accurate completion of the Braden Scale nutrition sub-score. The Centers for Medicare and Medicaid Services (CMS), Minimum Data Set (MDS) 3.0 Section M, Skin Conditions requires pressure ulcer risk assessment. Nursing facilities may use a formal assessment instrument such as the Braden or Norton tool to determine pressure ulcer risk. The most commonly used pressure ulcer assessment tool is the Braden Scale and one of the sub-scales is nutrition. Studies completed by Bergstrom and Braden in skilled nursing facilities found that 80% of pressure ulcers developed in two weeks after admission and 90% within three weeks of admission.

As a consultant dietitian to nursing facilities for 35 plus years, I review the Braden Scale as part of the nutrition assessment process. If completed accurately, the nutrition sub-scale elicits valuable information about the resident’s current nutritional status. However, from my experience, this section is frequently inaccurate. Adequate (3) or excellent intake (4) is often checked, when most individuals have inadequate (2) or very poor (1) intake at admission. Just because an individual is on a tube feeding or TPN does not mean that the current regimen is meeting their nutritional needs. For example, an individual who has just had a peg tube placed initially is probably not receiving the appropriate calories and protein required. In this instance, a sub-score of 2 (probably inadequate) should be checked. As a professional who is frequently requested to complete chart reviews for legal cases, I have encountered instances where adequate intake has been checked when in fact the person is NPO or only on an IV. This type of error does not help the facility that is defending a malpractice case.

Consider this scenario
A resident is admitted with the following areas checked: Sensory Perception 3–slightly limited; Moisture 2–often moist; Activity 2–confined to chair; Mobility 2–very limited; Nutrition 4–excellent; and Friction and Shear–1 problem, for a total of 14 or moderate risk. When the registered dietician (RD) evaluates the nutrition sub-scale score, the dietary intake is poor since the individual rarely eats two servings of protein a day and the fluid intake is below 1000mL/day. When this information is combined with the other scores the total should have been 11, or high risk for pressure ulcers. Does the individual confined to a chair with very limited mobility have access to a water pitcher and do they eat without staff assistance? If they are confined to a chair, are they also kept isolated in the room at mealtime?

The implementation of preventive protocols, including nutrition, is based on the total risk score plus specific needs of the individual. Regardless of the total risk score, if the nutrition sub-score is poor or probably inadequate, the staff should immediately contact the RD and act quickly to improve nutritional deficits.

Based on the research by Bergstrom and Braden, pressure ulcer risk assessment should be completed upon admission, then weekly for four weeks, monthly or quarterly after that and when there is a condition change. If this schedule is implemented, the staff is afforded multiple opportunities for accurately completing the nutrition sub-score. Join me as we achieve a campaign promise of accurate documentation to prevent pressure ulcers by improving or maintaining the nutritional status of nursing home residents.

About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Panel and the American Dietetic Association’s Unintentional Weight Loss work group.

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.