5 Skin Care by 8Quk68

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									                          SKIN CARE
        AFH COMPLAINT/INCIDENT INVESTIGATION PROTOCOL

PURPOSE
To guide investigation of allegations regarding care management of all skin conditions,
except pressure ulcers, to determine if failed facility practice relative to a statute(s) or
regulation(s) has occurred and if the failed practice(s) had, or has, the potential to contribute
to negative resident(s) outcome(s).

IMPORTANT CONSIDERATIONS
Providers may have limited knowledge and experience with measures needed to prevent,
monitor or deal with skin issues, whether existing or new. A resident’s condition or activity
level may decline while living in the home. Skin conditions may exist on admission and/or
may develop insidiously. For these reasons, when allegations of improper skin care are
received, a thorough evaluation of the resident’s skin care management and care needs
must be done to determine if the appropriate services have or are being provided.

This Skin Care Protocol can be used for investigation of allegations regarding inadequate
skin care management related but not limited to: abrasions, bruises, simple cuts, rashes,
arterial/ischemic ulcers, venous insufficiency ulcers (previously known as venous stasis
ulcers), psoriasis, diabetic neuropathic ulcers, non-surgical wound care and/or non-sterile
dressing changes. If applicable, refer also to the AFH Pressure Ulcers Protocol.

AUTHORITY
The following is a list of rules and regulations that pertain to skin care concerns. As
indicated by the reported concern, review these regulations and others that may apply.

Chapter 70.128 RCW – Adult Family Homes
Chapter 70.129 RCW – Long-Term Care Resident Rights
WAC 388-76-60070(2) – Other Resident Rights
WAC 388-76-61000 through 61080 – Resident Assessment
WAC 388-76-61070(2) – Revised Assessment
WAC 388-76-61500(1)(2)(3)(8) – Negotiated Care Plan
WAC 388-76-61500 through 61560 - Negotiated Care Plan
WAC 388-76-61550(2) – Revised Care Plan
WAC 388-76-620(1)(4)(a)(b)(c)(5) – Provision of Services and Care
WAC 388-76-625 – Nurse Delegation – Training and Registration
WAC 388-76-630 – Performance of Delegated Nursing Care Tasks
WAC 388-76-635 – Nurse Delegation – Penalties
WAC 388-76-655 - General Management and Administration
WAC 388-76-675(2)(3)(a)(b) – Reporting Requirements
WAC 388-112-0195 – Nurse Delegation Core Training – Who & When

I. OFF-SITE PREPARATION
Review pertinent section(s) of RCS C/I Guidance. In addition, remember:
 RCS staff must not physically inspect resident’s skin by themselves




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   Direct skin care observations are done with the resident’s or resident representative’s
    consent.
   Direct skin care observations are done only in the presence of, and with the direct
    physical assistance of, staff in the AFH.
   If you are a Long-Term Care AFH Licensor, you will need to coordinate with a Nurse
    colleague and your Field Manager for follow-up skin observations.
   Refer to the AFH Pressure Ulcers Protocol for direction if the skin issue is only or also
    pressure ulcer in nature.

A. Identify/Clarify Issues
   If information reveals the concern is not within RCS’ statutory jurisdiction, refer to
   MB R07-010 – Operational Principle and Procedure for CRU Complaint/Incident Referral
   Processing in Field Offices, for guidance and actions to take.

    Review the Complaint Intake Routing Form to determine what all is to be investigated
    on-site.

    Complainant Interview
     Does the resident have any open areas or other skin problems?
     How long have skin issues been present?
     How did you find out about the open areas or other skin problems?
     What do you think caused the skin problem(s)?
     Has the resident been seen by their primary health care practitioner? If not, why?
     How is the provider addressing the skin problem(s)?
     Does the skin seem to be improving?
     What other agencies are involved in providing the resident’s skin care?
     When do you usually visit the home and the named resident(s)?
     What kinds of things do you observe staff doing for the named resident(s)?

B. Preliminary RCW/WAC Selection:
   As part of the off-site investigation plan, determine the number of allegation(s) to be
   investigated, as identified on the Complaint Intake Routing Form from CRU and from
   any additional information obtained prior to going on-site. Identify in advance the likely
   applicable statutes and/or regulations that address the allegation(s) to be investigated.
   If the investigation determines additional unalleged failed facility practice(s), go back
   and determine additional RCW/WACs applicable for these citations, as well.

C. Review History
   Review RCS C/I Guidance, Section II.

D. Plan Approach to Investigation
   1. Special Considerations
      Review pertinent section(s) of RCS C/I Guidance. In addition:
       Initiation of On-site Investigation: Based on information obtained, decide if the
         investigation should start in the AFH or another setting (such as observing the
         resident in the hospital).
       Consult with your Field Manager when you believe the investigation should begin
         outside of the AFH.


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   2. Observation Planning
      Review pertinent section(s) of RCS C/I Guidance. Pertinent to the alleged skin
      issue(s), do an initial tour as appropriate and then focus your skin-related
      observations on the named resident(s), other resident(s) in the sample and the
      environment of the AFH.
       Initial observations should be directed at the named resident and the
          environment, focusing on factors that could contribute to skin conditions,
          excluding pressure ulcers.
       If the home has primarily elderly or medically comprised residents, or the named
          resident is no longer in the home, immediately consult with your Field Manager
          about whether or not to do skin observations on other residents at risk for skin
          impairment, excluding pressure ulcers.

  General Observations             Resident Observations               Staff Observations
Where are the residents?        General condition of skin,        Who is involved in the
                                signs of compromised              resident’s skin treatment and
                                nutrition and/or hydration?       resident’s skin care?

What do they look like? Are     Resident wet/soiled?              Turning, repositioning, and
they primarily elderly,                                           other interventions observed?
immobile, etc.?
How are they positioned if      Pressure on compromised           Proper techniques used to
they need help by staff?        skin area(s) from:                avoid skin damage when:
                                * Poor positioning?
Pressure reduction and          * Lack of, or improperly          * Assisting the resident with
pressure relieving measures       used, pressure reducing           turning and repositioning?
evident?                          and/or pressure relieving
                                  mattresses or cushions?         * Transferring the resident?
                                * Improper fitting shoes or
                                  clothing that binds or rubs?

Food and drinks accessible to   Observe the site(s) and other     Timely toileting or changing of
them?                           areas with potential for skin     incontinence products?
                                impairment, only after consent
                                and with AFH staff help, as
                                appropriate to your discipline.

Braces, splints applied         Carefully document the size       Thorough peri-care?
correctly?                      and condition of the
                                skin/wound(s), excluding
Wheelchairs/assistive devices   pressure ulcers.                  Proper infection control
with protruding objects or                                        techniques:
unpadded areas?                                                   * Hand washing?
                                                                  * Linen handling?
Hazards – objects cluttering                                      * Glove usage?
hallways/pathways with                                            * Infectious waste disposal?
potential for injury to skin?




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   3. Interview Planning

   Resident(s) /Family/ Representative(s)                     Provider/Staff
Are there open areas that are not pressure      Does the resident have any current skin
ulcers or other skin problems for you or the    problems?
person you’re concerned about?

Do you know when they developed?                Do you know when they developed?

Has the resident had skin impairment or         Has the resident had skin impairment/skin
other skin problems in the past?                problems before?

Has the resident been seen by a health care     What did you do to prevent this skin
professional for current skin problem(s)?       problem?

Do you know what might have caused the          Who has been notified of the resident’s skin
current skin problem(s)?                        problem(s)?

What are they doing to treat the skin           Has the skin problem been assessed by a
problem(s) now?                                 health care professional?

Does it seem to be getting better?              How is it being treated?

                                                Is it getting better?

                                                How is the resident eating and drinking?

                                                Are you doing anything special to improve
                                                the resident’s hydration or nutrition?

                                                Do you have any other residents with skin
                                                issues? If so, who and what type of skin
                                                issue(s)?



   3. Record Review Planning
      Make preliminary decisions regarding which records need to be reviewed and make
      adjustments based on information obtained once on-site.


II. ON-SITE ACTIVITIES

Based on information obtained during the on-site investigation, expand observations and
interviews, as needed. In addition, add to the Record Review section:




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       Record Reviews
        Wound skin documentation may or may not be present. Ask to see the injury log.
          Check all possible sources of records for relevant skin information.

    Resident(s) /Family/ Representative(s)                      Provider/Staff
 What are the pertinent diagnoses,               Personnel file – Focused review of current
 especially those with potential to contribute   AFH staff to determine if caregiver(s) are
 to skin problems?                               qualified and, pertinent to skin care
                                                 management, have they had the
 Prior history of arterial/ischemic ulcers,      appropriate training and/or RN Delegation?
 venous insufficiency ulcers, diabetic ulcers,
 burns, rashes or other skin issues?

 Is documentation of the skin problem
 congruent with what the provider has said
 happened, i.e. when it started, what has
 been done, etc.?

 Is there a current skin assessment? Does
 the assessment and appearance of the skin
 problem correlate with provider/staff
 interviews and with observations?

 What is the treatment plan? Is it
 updated/ongoing?

 Is the skin problem healing?

 Who is involved in treating the skin
 problem? Document their name/contact
 information.

 Who has been notified of the skin problem?
 How timely? How often, especially if skin
 problem(s) not resolving?



       Review and Analyze Data
       Determine if sufficient information has been obtained to answer key questions about
       failed facility practice and negative resident(s)’ outcomes.
        Did the skin condition issue(s) develop after the resident was admitted to this
            AFH?
        Did the AFH’s assessment identify the resident at risk for skin impairment?
        Were the negotiated care plan and the caregivers’ implementation of the plan
            sufficient to minimize the development of prior skin issues and/or heal the skin
            conditions(s) currently present?



AFH Skin Care                            April 2007                              Page 5 of 6
          Is there sufficient data to justify reviewing the AFH Pressure Ulcers and/or
           Neglect Complaint/Incident Investigation Protocols? If yes, proceed to do that
           review and collect additional data (observations/interviews/record reviews) as
           applicable.
          Consider if you need to make contact with outside agencies involved in treating
           the resident’s skin problem(s) to further determine condition and progress of skin
           healing with current treatment plan.
          Consider if you need to make an RCS request for record(s) to other agencies/
           primary health care practitioner, if/as applicable.
          Do a brief review of the “Key Triggers” documents.

Talk to your Field Manager when applicable prior to leaving the facility to determine if any
additional data may need to be collected and analyzed.

Status Report/Exit Conference:
      Use this opportunity to explain preliminary findings and identified deficiencies to the
      provider or provider representative to provide them with an opportunity to ask
      questions and present additional information. Ensure provider or provider
      representative is aware of resident issues that need immediate attention. See page
      21 of RCS C/I Guidance for details of this last task to be done prior to exit from the
      home or the last day of on-site data collection.


III. OFF-SITE ACTIVITIES & FINAL DETERMINATION

Review pertinent section(s) of RCS C/I Guidance. In addition, complete the following tasks:

   1. Final determination of failed facility practice with regulation(s).
   2. Inform provider of final outcome of investigation.
   3. Complete a Statement of Deficiency and related enforcement activities (if
      applicable).
   4. Make necessary follow-up referrals to the CRU if/as applicable.




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