Is it necessary to document on the care plan the routine interventions we provide, such as a pressure-redistribution mattress or daily skin inspection?

Yes. Providers need to ensure the medical record accurately reflects the care provided. As the nursing saying goes, “If it’s not documented, it wasn’t done.”

While we know we tend to provide care daily that we don’t document, providers need to attempt to ensure the care provided is clearly captured in the medical record. The in-house pressure-redistribution mattress is a good example of an intervention automatically provided in most facilities. Thus, many providers do not place it on the skin-integrity plan of care. However, when working with claims and surveys, we must be able to prove a pressure-redistribution mattress was provided.

At a minimum, all skin-integrity care plans should address the following interventions as appropriate: a pressure- redistribution mattress for the bed, a cushion for the wheelchair/sitting surface, turning and repositioning, heel elevation, incontinence management, nutritional support, daily skin inspections with care by the caregivers, a weekly head-to-toe skin assessment, risk assessment per facility policy, and notification of the physician and family/designee if a skin condition is found.

If the resident has a current pressure injury, the care plan should at least address all the above interventions plus the following interventions as appropriate: topical management as ordered, weekly wound assessment, pain management, monitoring for signs and symptoms of infection and decline, and notification of the physician and family/designee if there is a decline.

Lastly, ensure the interventions are communicated to the nursing assistants on their assignment sheets.

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