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By Tamala Sammons, M.A. CCC-SLP, Senior Therapy Resource

F-Tag 686: Skin Integrity; Pressure Ulcers/Injuries

Surveyors will assess how a facility is doing based on the comprehensive assessment of a resident, and ensure that:

1. A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and
2. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

How can Therapy help be a partner to ensure the facility has a strong skin system? Start by asking a few questions:

● Is skin integrity and risk for pressure ulcers assessed on every Therapy evaluation? Should it be?
● Do therapy assessments include other risk assessments, i.e., tissue tolerance testing? Pain? Nutrition/Hydration? Incontinence?
● When OT is working on showers with patients, in addition to focusing on ADLs, do they assess the patients’ skin?
● How often does PT remove a patient’s shoes/socks to assess a patient’s feet?

There are a wide variety of clinical areas that Therapy can assess and treat to ensure residents have good skin integrity, reduce risk for pressure ulcers/injury, and actively treat wounds.

Pressure Points and Tissue Tolerance
An at-risk resident who sits too long in one position or is known to slouch in a chair has an increased risk for pressure ulcers/injuries. Elbow pressure injury is often related to arm rests or lap boards. Friction and shearing are also important factors in tissue ischemia, necrosis and PU/PI formation. PU/PIs on the sacrum and heels are most common.

● How often does Therapy assess for pressure points and tissue tolerance?
● Does Therapy assist with the completion of the Braden Scale? Your clinical partners would love the assist!

Positioning and Support Surfaces
Once the IDT identifies who is at risk, how do they determine the needed support surfaces, proper positioning and/or repositioning frequency? Do they take into consideration the individual’s level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort? Appropriate support surfaces or devices should be chosen by matching a device’s potential therapeutic benefit with the resident’s specific situation.

● How does Therapy engage in assessing the appropriate positioning and support surfaces?
● How often does therapy assess residents to ensure the recommended positioning and support surfaces are in place, still meet the needs for each resident, and provide reviews/updates of the resident care plan?

Active Wound Care
PT intervention for active wound care is appropriate when any of these exist: Necrotic material is present in the wound bed; the wound is a stage 3 or 4 pressure injury; the rehab potential is good to meet stated goals; and/or the wound has an impaired healing process.

● Do we have a physical therapist on staff who treats wounds?
● Are we up to date on all the various wound care interventions, such as: scalpel debridement; closed pulse irrigation; ultrasound MIST; and/or other modalities?

Incontinence
Both urine and feces contain substances that may irritate the epidermis and may make the skin more susceptible to breakdown and moisture-related skin amage.

● What is Therapy’s involvement with incontinence intervention?

Nutrition and Hydration
Adequate nutrition and hydration are essential for overall functioning. It is critical that each resident at risk for hydration deficit or imbalance, including the resident who has or is at risk of developing a PU/PI, be identified and assessed to determine appropriate interventions.

● Is SLP involved as part of Skin IDT?
● Is the Think Thin program in place?

Contractures
A resident with severe flexion contractures also may require special attention to effectively reduce pressure on bony prominences or prevent breakdown from
skin-to-skin contact. Some products serve mainly to provide comfort and reduce friction and shearing forces, e.g., sheepskin, heel and elbow protectors.

● What is Therapy’s role with contractures? How often is skin/skin hygiene assessed?
● Does Therapy have an active hand/skin hygiene program?
● How often does Therapy assess splints’ effectiveness for not only the contracture but also skin integrity?

Pain
The assessment and treatment of a resident’s pain are integral components of PU/PI prevention and management. Pain that interferes with movement and/or affects mood may contribute to immobility and contribute to the potential for developing or for delayed healing or non-healing of an already existing PU/PI.

● What therapy assessments are completed to determine any pain levels?
● Are modalities used for pain management?
● Is level of pain discussed during skin IDT meetings?

Training, Education and IDT Collaboration Resources

● Refer to chapter VIII page 82 of the RNA manual for information that can be used for training CNAs and/or RNAs on skin and positioning. https://portal.ensignservices.net/Departments/Clinical-Resource-Tools/Manuals/manuals Scroll down or type in the search Restorative Nursing Program Manual.
● Refer to the EPIC section of the portal https://portal.ensignservices.net/EPIC/skin for education, information, and other resources for an IDT approach for skin.
● Refer to the Pressure Ulcer/Injury Critical Element Pathway. This can also be found on the portal. https://portal.ensignservices.net/Departments/Clinical-Resource-Tools/CMS-Requirements-of-Participation/CMS-TOOLS/NEW-SURVEY-PROCESS/critical-element-pathways
● Refer to a variety of supportive POSTettes for additional information: Wound Care, Contractures, UI, UTI, Pain, Nutrition/Hydration.

By Gina Tucker-Roghi, Alexis Renfro, and Ali Vandeloo, Rock Creek of Ottawa, KS
Looking for opportunities to increase your community outreach and develop your outpatient program? Rock Creek of Ottawa is putting a new spin on the Abilities Care Approach. Ali Vandeloo, DOR, worked with Alexis Renfro, an OT and TEACHA (Therapy Expert on the Abilities Care Holistic Approach), to bring an abilities-based approach to dementia care to their community through outpatient programming. Ali and Alexis have broadened the scope of services at Rock Creek by promoting aging-in-place for individuals with early-stage dementia.

Our outpatient Abilities Care Approach programming incorporates the familiar aspects of the Abilities Care Approach with training, support and education for family caregivers to target the following clinical outcomes:

1) Increase caregiver self-efficacy through education on approaches and techniques to manage challenging behaviors
2) Prevent falls and injuries
3) Maintain meaningful relationships and engagement with family, friends, and the community
4) Maintain function, prevent functional decline and mitigate risk factors related to dementia

Since launching the pilot of this program, Rock Creek has provided outpatient services to eight individuals living with dementia in the community. One of our first clients was an individual with middle-stage dementia living with her husband in the community. We provided education and support for the caregiver to enhance the care he provided for his wife. Our interventions focused on maintaining a healthy routine, prevention and management of neuropsychiatric behaviors, prevention of falls and injuries, participation in meaningful activities, utilization of sensory strategies to improve engagement, and utilizing their authentic and meaningful context to personalize her care and experience. As a result of our services, he learned new approaches and was more confident in his ability to care for his wife.

Another client was an individual with early-stage dementia and depression. She was living home alone and had been a rehab patient at Rock Creek prior to discharging home. She received outpatient services post-discharge to help her integrate health-promoting behaviors and habits into her daily routines and was able to stay in her home and remain engaged in her community through activities with her church and volunteering.

An outpatient ACA program can help you achieve the following facility and community outcomes:
1) Create rapport and relationships with families in the community that may result in opportunities for future admissions for respite or long-term care services in your SNFs or Als

2) Increase community awareness of the scope of facility services throughout the continuum of care

3) Attract new therapists and grow your therapy department

4) Minimize the stigma of dementia and increase knowledge and understanding of members of your community who interact with individuals living with dementia

Here are a few tips if you are ready to get started:

1) Start with patients already under your care (patients discharged from post-acute to home or residents at your on-campus or affiliated ALFs).
2) Become familiar with the existing community resources for individuals living with dementia.
3) Network to get to know service providers for individuals with dementia who live in the community. Here are some examples:
a) Area Agency on Aging
b) Meals on Wheels
c) Geriatrician or dementia clinic
d) Alzheimer’s Association
e) Dementia caregiver support groups
f) Adult day health programs

If you are interested in giving Outpatient ACA a try, join our bi-weekly call of early adopters. We gather every two weeks on Wednesday at 9 a.m. PST. Our next meeting is April 20. Please email Gina Tucker-Roghi groghi@ensignservices.net to be added to the call invite.

Partnering with Nursing: F-Tag 689

Submitted by Tamala Sammons, M.A. CCC-SLP, Sr. Therapy Resource
Federal Tags (F Tags) are the minimal Federal and State Standards of Care that are used to survey Skilled Nursing Facilities as a measure of performance. Rehab Services provides an important role in order to ensure compliance with these standards by having strong systems for IDT collaboration, patient identification, and providing skilled intervention programming.

“Assistance Device or Assistive Device” refers to any item (e.g., fixtures such as handrails, grab bars, and mechanical devices/equipment such as stand-alone or overhead transfer lifts, canes, wheelchairs, and walkers, etc.) that is used by, or in the care of a resident to promote, supplement, or enhance the resident’s function and/or safety.

• Are Safety Assessments part of therapy evaluations? Are they completed during different times of the day with various scenarios?
• How often does therapy engage in assessing assistance devices and providing staff education on proper use? How often does therapy assess to see if those devices are still the best option for each resident?
• Does therapy use a gait belt on patients anytime they require more than a supervision level of assistance?
• Is Therapy familiar with what’s on the care plan and helping to ensure it’s accurate for device usage?
• Is Therapy familiar with the CCA audit specific to this tag?

“Fall” refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.

• Do all disciplines get involved to determine who is a fall risk and what interventions to use?
• The evaluative phase for fall prevention shouldn’t end with one assessment. Patient behavior over time needs to be measured to determine the best interventions.

• Are we using various standardized tests that tell us who is at increased risk for falls such as:
• Do we assess gait velocity or just distance?
• Does therapy take time to ensure a new admit or a resident with a room change is oriented to their new environment? Is the environment set up in the best way for this patient’s success?
• Does Therapy use a gait belt on patients anytime they require more than a supervision level of assistance?
• Is Therapy familiar with the CCA audit specific to this tag?
• Does Therapy attend COC/Falls meetings?

Best Practice Ideas

• We have Therapy representation attending and contributing ideas for Incident and Fall meetings.
• We do ongoing therapy assessments for positioning, transfers, seating set up, etc. as fall prevention. NOTE: also ensure Care Plan is updated with the correct recommendations!
• We provide education to Nursing on how Therapy can help with both fall reduction and post-fall support. ALL disciplines! Be sure to cover how much SLP can do around cognition. Our SLPs work on fall reduction as much as PT!
• Therapy has increased communication to nursing in PCC in addition to various “paper forms” many facilities use.
• We do CNA huddles to ask about their concerns or recent changes with any residents.
• We complete a full battery of dx tests over more than one day to get a more comprehensive picture of how patients are performing.
• We participate in facility rounds/safety committee
• We participate in ongoing reviews of care plans for level of assist recommendations. We avoid ranges of assist (i.e., 1-2) and really dig into what each resident needs for that activity.
• We do an IDT post-fall meeting outside of a meeting room; we go to the resident and ask them to “re-enact” what happened. We assess environment and figure out any unmet needs of the resident at the time of the fall.
• Vital signs, vital signs, vital signs! We measure vital signs pre-, during, and post-treatment to assess for changes; we also complete orthostatic blood pressure testing on all residents and know who is at risk.
• Environment: We assess room setup, bathroom setup (i.e., does the current position of grab bars work for the residents in that room, toilet height, etc.).
• New admits and room changes: we assess the success of residents’ ability to function safely upon admission or after a room change (maybe they were closer to the bathroom and now they are not), as this is a new environment and it can be confusing to navigate, especially at night.
• Our OT has helped tremendously with our low vision population, adjusting the lighting in rooms and adding colored codes to remotes/call lights.
• We noticed a pattern of skilled patients falling within a day or two of admission. The Falls Team felt that this was due to the fact that there was no wheelchair available upon admission, as Nursing was waiting for Therapy to eval for transfers, etc. It led to patients attempting to transfer themselves because they did not have that visual reminder to wait for assistance. We attempted to solve this problem by having the rehab tech place a wheelchair in the patient rooms prior to admission so the reminder was there upon arrival. We noted a decline in subsequent falls around 18% month over month following this implementation.
• We noticed that quite a few falls were happening due to the patient’s need to toilet. The PTs jumped on board and decided to start a day shift toileting program whereby we scheduled time daily for the skilled patients who had fall risk factors. One therapist would have those patients scheduled for regular therapy and then follow up during the second half of their day to perform the toileting for the assigned patients for the day. They were successfully able to get those patients to the toilet twice throughout the four-hour shift, while also being able to bill time for functional activities as indicated. The two weeks we were able to run the program so far evidenced no falls on shift (and high patient satisfaction 😊). Our next step is to include all PTs and OTs on a rotating basis to perform toileting rounds on day shift and see how this impacts our falls.
• We communicate important updates and changes using the KARDEX for CNA/Nurse Easy Access.

By Shelby Donahoo, Therapy Resource, Arizona

Month in, month out, COVID or no COVID, Sabino Canyon in Tucson, AZ, leads our organization in group and concurrent metrics. Averaging around 30% in both skilled and long-term care provision, it’s just become part of the facility culture. Executive Director Jaron Watson, DNS Quinny Mazzola, and TPM Dora Alvarez spoke to the Tucson market at an ED/DNS/DOR meeting last month to discuss.

“It’s about partnership,” they all said. “There aren’t ‘department goals’ but all-inclusive “facility goals.” Nursing is just as invested in rehab metrics as their own, and vice versa. There is an understanding of the benefit of group and concurrent for the residents and the facility from an IDT perspective, so it’s considered a group effort to achieve this metric.

Sabino Canyon runs an extremely busy skilled and long-term care program and services, so services need to be focused on function from day one. With a combination of group and one-on-one services, we get to spend more time with our patients overall, and our patients receive longer rehab services during a given day,” said Dora. This is a philosophy adapted with PT, OT and SLP.

With results creating buy-in from the Rehab team, a full understanding of more patient rehab time = better outcomes, and operational impact is discussed on all levels. Having patients up and ready for groups throughout the day becomes an expectation. Systems and flexibility are critical to this project:
● Each nurse’s station has a group schedule dry-erase board, showing time of group and patients scheduled for the group daily
● Rehab front-loads “on the unit” sessions the first few days of stay to incorporate much CNA training and sharing of individual patient goals
● Dry-erase boards with pictures of patient levels (mobility, device, etc.) are in each patient’s closet; Nursing uses a report sheet with diagnosis, precautions, etc. for quick reference as to patient concerns and assist needs
● Nursing, Therapy and Admissions consider the ability to do groups and concurrent treatment provision with roommate placement

Skilled long-term care groups have morphed into RNA groups. Self-ROM and AAROM groups are popular. Specific exercise groups are taught to Activities. One 3x/week exercise group is led by one of the residents.

Congrats, Sabino ,on your ability to “think out of the box” and amazing teamwork!

By Carly Peevers, SLP and Andrew Folmar, OT Rosewood Rehabilitation, Reno, NV

You’ve done the assessments, sensory profiles, interventions, accumulated all this information about your residents to create a specific maintenance program within their Allen Cognitive Level, but what now? How do we effectively share and educate the caregivers to create a successful functional maintenance program and have a place where they can reference this information as needed? This was a question we had early on in the Abilities Care Approach, and that’s when our facility implemented activity cards.

Activity Cards are a summary of the information collected throughout the intervention which may include:
• Stage specific recommendations within different environmental and activity demands, personally relevant activities with modifications and strategies for this patient,
• Pertinent life history and
• Sensory information that may assist in engagement and/or management of behaviors
in order to increase meaningful engagement, quality of life, and maintenance of cognitive and/or communicative function.

What does the Activity Card look like on paper? We use a tri-fold pamphlet to present our information. The front has a color outline corresponding to their ACL level (red, orange, yellow, blue). On the inside there are three columns.
• The first provides a list of activities/interests and modification recommendations.
• The second column is a summary and description of current abilities in cognition (attention, problem solving, sequencing etc.), communication, physical strengths and limitations during ADLs, and possible barriers in their cognitive function.
• The third column is a running shopping list that incorporates this patient’s personal interests and functional needs (grooming/hygiene supplies, sensory stimulation tools, clothes, etc.). We attach this pamphlet to the patient’s life history board with Velcro so it is easily accessible to all caregivers and support staff for a quick reference.

We hope this information helps others with their caregiver engagement for dementia residents.