Nosocomial Pressure Ulcers in a Nursing Home, Thesis of Business Accounting

Download Nosocomial Pressure Ulcers in a Nursing Home and more Thesis Business Accounting in PDF only on Docsity! 1 Running Head: Task 1 C493 C493 Leadership and Professional Image Task 1 Western Governor’s University A1: PROBLEM OR ISSUE The problem is nosocomial pressure ulcers in a nursing home. A1A: EXPLANATION OF PROBLEM OR ISSUE I work as a registered nurse in a nursing home in Queens, NY. In my facility, it was observed that in one unit, there was a surge of nosocomial pressure ulcers. In a course of two weeks, 7 nosocomial pressure ulcers developed. The facility has a policy in place for pressure ulcers-prevention and treatment. This is a policy for patient safety. Development of nosocomial pressure ulcers are bad clinical practice and can invite lawsuits and penalties. Resident safety is compromised and can lead to other issues like dehydration, infection and failure to thrive. Pressure ulcers can not only be costly to the facility but also severely impact a resident’s life as well as prevent the prescriber from giving appropriate care and treatment to the resident (Preventing Pressure Injuries, July, 2016). A2: INVESTIGATION On investigation, it was found that that there was a CNA in one of the assignments who was not turning and positioning the residents every two hours. She was not changing the residents in a timely manner. The residents in that assignment required extensive to total assistance in activities of daily living and are dependent on staff for their daily care. When this care was not 2 Task 1 provided in a timely manner, they developed pressure injuries. I spoke to the staff members and we all agreed that if staff does not follow the policies, then lapses in care occur and resident care is compromised. A2A: EVIDENCE OF PROBLEM OR ISSUE The quality measures for long term residents for our facility are 10.6% as compared to state average of 9.4% and the national average of 8.1%. Pressure Ulcers are a sentinel event and are a cause of multiple lawsuits and infections in residents (Quality Measures, October 19, 2020). A3: ANALYSIS Policies are effective only when people follow them. In this case, the policy of turning and positioning and check and change was not followed. The pressure ulcers developed due to human error. Errors do happen and we should have safeguards in place to catch these errors as well as a plan to prevent them in the future. A3A: CONTRIBUTORS TO PROBLEM OR ISSUE: Facilities rely on staff members to follow the policies for resident care. People do make errors. The errors are made if staff wants to save time, energy or wanting to rush to finish the work. There are other factors which play a part in causing these errors such as floating staff, difficulty in turning and positioning and higher body weights of the residents. A4: PROPOSED SOLUTION OR INNOVATION A solution to prevent nosocomial pressure ulcers is to have a type of bed that aids in turning and positioning the resident to prevent skin shearing. There should also be an alarm that is connected to a pager that is provided to the CNAs for their patient beds that buzzes every two 5 Task 1 A8: IMPLEMENTATION Implementation of all these measures would also require a policy in place. Staff will be trained and in-serviced. Staff will also be trained to use the new beds and alarms. After the staff is trained, there will be a roll out date for implementation of the measures. Staff will continue to be in-serviced every three months and an open line of communication will be maintained. B1: ROLE OF SCIENTIST I was a scientist as I collected, sorted and researched the data. I also conducted interviews with the staff and collected my own data. This data was used to assess the problem, evaluate and find a solution. B2: ROLE OF DETECTIVE I worked as a detective as I investigated the problem and determined the need for change. Policies were developed. B3: ROLE OF MANAGER OF THE HEALING ENVIRONMENT A chance was provided to the unit to grow a culture of safety and policy change. The manager must reinforce the policy change from time to time and also make sure that all staff is participating in the education and implementation of the new policies. 6 Task 1 References Quality Measures. (2020, October 19). Centers for Medicare and Medicaid Services. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ NursingHomeQualityInits/NHQIQualityMeasures The Joint Commission. (2016, July). Preventing Pressure Injuries. Quick Safety: An Advisory on Safety and Quality Issues. Retrieved from https://www.jointcommission.org/- /media/deprecated-unorganized/imported-assets/tjc/system-folders/joint-commission- online/quick_safety_issue_25_july_20161pdf.pdf?db=web&hash=A8BF4B1E486A6A67 DD5210A2F36E0180