Introduction

Resident Selection

Residents included

  1. Residents who had an active wound care order in PCC and were present in the facility when the audit ran.

  2. Residents with an ICD-9 diagnosis for Stage 3, 4, or unstageable pressure ulcers are included in this audit and are assigned additional task(s).

Business rules

Tasks

  1. Interventions are recorded in the care plan for residents who are documented as having refused wound care. (Q707)

    1. Location in PCC: 

      1. Refusal of Care Identified: TAR 

      2. Focus and Interventions: Care Plan

    2. Business Rule:

      1. IF a resident is receiving wound care,
        AND the resident refuses wound care (as recorded in the TAR)
        THEN the resident must have a focus in the care plan for refusal of care and an intervention for this focus addressing the recent refusal of care

    3. Due Date:

      1. A new intervention must be added on the day of the wound care refusal

    4. Is classified as missed on the report:

      1. The day after the wound care refusal

    5. Is no longer relevant to the report:

      1. If the wound care order is no longer active

**Due to lag between reception of the TAR data, the information regarding this task will only be available to be viewed historically and will not appear on the current date of the Nurses Audits Report.


  1. Active care plan that indicates risk for wounds (Q709)

    1. Location in PCC:

      1. Care Plan

        1. Focus

        2. Interventions

    2. Business Rule:

      1. IF a resident has an active order for wound care
        OR has a diagnosis of a stage 3, 4, or unstageable pressure ulcer,
        THEN there must be an active care plan with a focus for wound care/compromised skin integrity 
        AND an intervention in that focus to address the wound care. 

    3. Due Date:

      1. 24 Hours after the first order for wound care
        OR  24 Hours after the first diagnosis of a stage 3, 4, or unstageable pressure ulcer OR

      2. 3 weeks after admission for new residents

    4. Is classified as missed on the report:

      1. N/A

    5. Is no longer  relevant to the report:

      1. If the wound order is no longer active