Palisade Healthcare Center

Review of the provider's updated July 2025 Skin Integrity policy revealed:* In an effort to maintain the resident's optimal level of skin integrity and promote healing of skin ulcers/pressure ulcers/wounds, the facility has a systemic approach and monitoring process for evaluating and documenting skin integrity. In the event that a resident is admitted with or develops a skin ulcer/pressure ulcer/wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcers/pressure ulcers/wounds.* The resident's skin is inspected daily with completion of ADL's [activities of daily living] (unless [the] resident is independent in ADL completion).

Changes in the resident's skin are reported to the Licensed Nurse (LN).* Ongoing evaluation continues weekly with the LN completing a full body skin audit.

Completion of the skin audit is documented on the treatment administration record (TAR) with their initials.* If skin impairment is noted after admission (in addition to the above steps), the LN:a.

Initiates alert charting.b.

Completes (and documents) notifications to the medical provider and resident or resident representative.c.

Implements new interventions as needed.

Documents on the resident's care plan. d.

Notified Food and Nutrition Services Manager (FANS) and/or Registered Dietitian of new pressure injury or worsening wound condition for nutritional needs evaluation.e.

Notifies Director of Nursing Services (DNS) of skin impairments that indicate a potential significant change in condition (Stage II or greater Pressure Ulcer, surgical wound dehiscence, hematoma, or bruise on an area of the body not usually vulnerable to trauma (e.g. head, breasts, inner thighs, groin). f.

The DNS and/or designee complete a comprehensive review of the resident's medical record to evaluate if the pressure injury was avoidable or unavoidable.

This evaluation is documented in the nurse's notes.

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