1. Pressure Injury Prevention Accreditation ROP Compliance

2. Each Clients risk for developing a pressure injury is assessed and interventions to prevent pressure injuries are implemented

3. Major Tests of Compliance
An initial pressure injury risk assessment is conducted for clients upon admission using a validated, standardized risk assessment tool.
The risk of developing pressure injuries is assessed for each client at regular intervals and when there is a significant change in the clients status

4. In Covenant
Braden Risk assessment for Inpatient adults in the Nursing assessment record
Present on admission form (POA)
Skin Condition in Patient Assessment Record

6. Daily Braden Scale Risk Assessment

7. Skin Condition

8. Major Tests of Compliance
Documented Protocols and procedures based on best practice guidelines are implemented to prevent the development of pressure injuries
Interventions identified in ADL page in Nursing Assessment Record and Patient Care Record

9. Braden Interventions Braden Interventions are identified in
The 24 hour flow chart/ Activities of Daily
Living.
Remember: If this does not provide a clear picture, Use the Patient Care Record notes to provide more information

10. Interventions Interventions are implemented to:
- prevent skin breakdown
- minimize pressure
- Reduce shear and friction
- Reposition
- manage moisture
- optimize nutrition and hydration
- enhance mobility and activity

11. In Medicine @ Covenant Consult Registered Dieticians
Medicine Skin Integrity Champions
Use of Therapeutic surfaces – air mattresses, ROHO cushions etc..
Consult with Wound Care Specialist
Discuss needs in Rapid Rounds
Use the Dr.s Board to
communicate needs
Turning Protocol – Q 2 hours – Standards of Care document TAPS and Air Tap - turn and positioning system Comfort Rounds Documentation on ADL page of nursing assessment record Documentation in Long hand of nursing assessment record Kardex for communication of interventions Walk with Me Program

12. Minor Tests of Compliance
Team members, clients, families, and caregivers are provided with education about the risk factors and protocols and procedures to prevent pressure injures

13. In Covenant
Pressure Injury Prevention (PIP) pamphlet is given to patients Pamphlets are also available on unit and in hallways Remember to chart when you have provided your patients with education

14. Patient Information

15. Patient Information – Back Side

16. Minor Tests of Compliance
The effectiveness of pressure injury prevention evaluated, and results are used to
make improvements when needed.

17. In Covenant
Policy outlines that any facility acquired pressure injury will be recorded as an adverse event in the RLS
Pressure Injury Prevalence – Identified with the POA form and audits
Pressure Injury Intervention Audits – Completed by the Skin and Wound Champions
Results used for action planning using the PDSA Cycle (Plan, Do, Study, Act)
Skin and Wound Champions and Clinical Nurse Specialist.

18. Perspectives to consider
Did the individual patient come in with a pressure injury? Did the patient go home with one or develop one while in our care? What interventions were put into place? Unit managers should have an awareness of the total number of pressure injuries on the unit and how many were facility acquired.

19. Questions?