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Understanding the Braden Scale with pressure ulcer management

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Ilene Warner-Maron, Ph.D.
Ilene Warner-Maron, Ph.D.

Recently, a 120-bed skilled nursing facility was cited by for pressure ulcer development. Records, as well as observations of the facility's residents, identified a significant number of newly transferred patients had developed heel pressure ulcers after admission to the nursing home.

The regulation states, “Based on the comprehensive assessment of a resident, the facility must ensure that 1) a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable and 2) a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.”

The facility used the Braden Scale upon admission and again when reassessments were completed for collection of Minimum Data Set information, assessments used both for the development of the interdisciplinary care plan as well as for reimbursement purposes. The initial physical assessments and Braden Scales were performed upon admission by either licensed practical nurses or registered nurses.

The majority of the residents who had developed pressure ulcers after admission were rated as having  low to no risk of pressure ulcer development. However, there was a high prevalence in the region of the country for diabetes, with significant numbers of residents both new and long-term having this diagnosis as one of a number of co-morbidities.

The Braden Scale is comprised of six domains that are independently scored by a nurse in order to predict pressure ulcer development and include sensory perception, moisture,  activity, mobility, nutrition, and shear/friction. Use of the Braden Scale by the licensed nursing staff did not result in the identification of increased risk to the heels or lower extremities as a consequence of diabetes. As a consequence of the lack of identification of pressure ulcer risk factors, interventions to reduce the risk as a preventative measure were not provided.


Root Cause Analyses were performed with nursing, rehabilitation services, central supply, admissions liaisons and administrative personnel to determine the etiology of the heel pressure “epidemic:” the disproportional development of pressure ulcers among newly admitted nursing home residents. The process used the Framework for Root Cause Analysis by the Joint Commission, which identified number of factors that contributed to the development of heel pressure ulcers:

  • Human Factors — the dependence upon the completion of the four corners of the Braden Scale without using nursing judgment to identify risk factors not included within the tool, including diabetes, peripheral vascular disease, pain limiting mobility, previous pressure ulcers or the presence of skin changes upon admission.

  • Staff Education — a series of in-services was provided to address knowledge gaps in the Braden Scale as well as ensuring that nurses use clinical judgment when performing nursing admission assessments to identify risk beyond the four corners of the tool.

  • Staffing Levels — The majority of residents were admitted on Friday evenings, a common finding among long-term care facilities who receive the bulk of their admissions from acute-care hospitals.  Despite this pattern, the administrator had not make adjustments to the staffing levels on Fridays, leading to incomplete resident assessments, inaccurate Braden Scale assessments the inability to access preventative pressure reducing/relieving devices.

  • Staff performance — Following the completion of the nursing assessment process by LPNs or RNs, no review of the documents was performed by supervisory nursing personnel. Residents with an increased risk of developing pressure ulcers over the heels as a consequence of diabetes, peripheral vascular disease or residents with limited mobility due to pain following surgery were not identified by the admission nurse.  The opportunity to identify and correct errors in assessment upon admission, to use errors in assessment as teachable moments and to improve accountability of the staff was lost.  Nursing staff were generally not assessing peripheral pulses as this information was not specifically required as part of the admission assessment.

  • Communication — Devices to reduce pressure over heels were provided following the completion of physical or occupational therapy evaluations by the licensed rehabilitation staff.  Communication between the nursing and therapy staff failed to timely identify appropriate devices for individual residents, particularly during the period from the admission on Friday evening until the resident was formally assessed on the following Monday.  During the interim period, the nursing staff did not have access to devices other than pillows, which could be used for heel floatation.

  • Risk Reduction — Although the nursing staff attributed the large number of residents with pressure ulcers of the heels  to diabetes, there were no preventative interventions instituted on admission to address the risk.  Changes were made to the orientation of new staff as well as on-going in-service education that focused on the skin care needs of the population served.

Multiple studies have demonstrated the validity and reliability of the Braden Scale. However the accuracy of the risk assessment is dependent upon an understanding of the multiple risk factors contributing to the development of pressure ulcers, particularly for residents with risk for lower extremity wounds.  

The Braden Scale assessment requires that staff exercise their nursing judgment in determining risk as well as interventions for long-term care residents with co-morbidities in order to avoid further epidemics of heel pressure ulcers.

Ilene Warner-Maron, Ph.D., RN-BC, CWCN, NHA, FCPP, is a clinical assistant professor at the Philadelphia College of Osteopathic Medicine and co-director of the Masters of Science in Aging and Long-Term Care Administration program.

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