Fall Prevention Program

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By Angela Anderson, PT, DOR, Gateway Transitional Care, Pocatello, Idaho
Therapy at Gateway has been honing in on fall prevention for several months now and has implemented many therapy interventions that are fairly standard in fall prevention. We have the therapists focusing on fall risk and fall prevention during the evaluations and recommending assistive equipment or strategies to prevent falls at that time. We had found that many of the falls were happening in the first day or two and that the therapy POCs weren’t having time to affect the outcomes. So, Therapy and Nursing developed some tools to help implement interventions as preventative measures when the admission nurse does the intake.

The admission nurses are already doing a fall risk assessment on intake. Our PT, David Cox, helped develop a 48-hour falls checklist that gives the admission nurse a list of areas to focus on and questions to ask that may help decrease the likelihood of fall, such as, “Have they been trained to use the call light and remote?” and “Is the clutter put away?” He also developed potential interventions for low-, medium- and high-fall-risk patients, depending on the result of the falls risk assessment tool. These lists give the admission nurse more interventions to choose from that may be applicable based on why the patients are triggering for higher falls risk.

Falls – 48hr falls checklistDownload
Falls – Risk ChecklistsDownload

This also helps demonstrate that we are proactively looking at fall precautions and putting interventions into place, checking them off and signing the form that can be scanned into PCC. The therapists can then reinforce the interventions that are put into place, modify if necessary, and focus CNAs on these interventions in addition to the traditional Therapy fall preventions.

David and Brooke (ADON) came up with some notification magnets for the doorways of patient rooms that identify high-fall-risk patients (for frequent checks), for patients with unstable vitals and orthostatic hypotension, to identify risks that help alert CNAs and staff to issues that need increased attention. Admissions is reporting that the program has potential to help and she can see the efficacy.

What Is Dysphagia? (Taken from the Dysphagia Research Society)

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By Elyse Matson, MA CCC-SLP, SLP Resource/Ensign Services
Swallowing is one of the most complex actions we perform, involving more than 30 muscles and nerves. The average person swallows approximately 600 times per day — about 350 times while awake, 200 times while eating, and around 50 times while asleep.

Dysphagia indicates any difficulty or problem with swallowing normally. A swallowing disorder not only affects safety but also quality of life. Dysphagia is a serious medical condition that affects between 300,000 and 600,000 individuals in the United States each year.

Common signs and symptoms of dysphagia include: difficulty with weight gain (in children), unintentional weight loss (in adults), coughing during eating/drinking, recurrent aspiration pneumonia, food/liquid coming out of the nose/mouth, and a feeling of food remaining “stuck” in the throat/upper chest, to name a few.

Dysphagia is associated with a wide variety of conditions, including congenital and developmental disorders (e.g., cleft lip/palate, Down’s syndrome), head and neck cancers, pulmonary conditions (e.g., chronic obstructive pulmonary disease), and a variety of neurologic conditions such as stroke, dementia, amyotrophic lateral sclerosis (Lou Gehrig’s disease), Parkinson’s disease, muscular dystrophy, cerebral palsy, and many more. Since it is a common symptom in many of these diseases, it often goes unnoticed and is often under-reported, despite having significant consequences.

Complications and consequences of dysphagia include pulmonary aspiration, malnutrition, dehydration, pneumonia and even death. In hospitalized patients, dysphagia has been shown to significantly lengthen the hospital length of stay and is a negative prognostic indicator. In addition, those with dysphagia often report a feeling of isolation and depression, as many are no longer able to take part in social gatherings that so often revolve around eating and drinking. It is estimated that dysphagia is responsible for between $4.3 to $7.1 billion in additional hospital costs per year. Despite the significant detrimental impact dysphagia has on health and quality of life, only a third of those afflicted seek medical treatment.

Assessment of dysphagia frequently includes a clinical assessment and instrumental assessment. A clinical bedside swallow assessment is typically completed by a speech-language pathologist (SLP) and is used to describe the characteristics of the individual’s swallow function, determine the presence/absence and characteristics of a swallowing disorder, determine the safest route of nutrition/hydration, and help provide additional recommendations for an instrumental assessment and appropriate treatment. The two most common instrumental assessments are fiberoptic endoscopic evaluation of swallowing (FEES) and modified barium swallow study (MBSS).

Once a diagnosis of dysphagia has been made, the healthcare team determines the most appropriate plan for treatment. Management of dysphagia may involve medical/surgical intervention by a physician and/or behavioral intervention by an SLP. The focus of any dysphagia intervention is to optimize the swallow to be as safe and efficient as possible, as well as to maximize the patient’s quality of life.

#APEXStrong

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By Amber Thompson, Market Leader, Keystone – Texas
Reaching the Highest Peak Is What Drives Us, But Reaching It Together Is What Matters
We would like to cordially invite you to be a part of the APEX challenge. Our focus over the past year has been on building leaders and transforming the way we serve our staff and residents. How do we create strong relationships within our IDT that are built on trust, accountability and love for one another? Performing physical challenges together as a team will create bonds between people that last a lifetime. The post COVID world has been a struggle for a lot of our operations. Employees are tired, some feel hopeless and some are lost in a spiral and can’t find their footing.

As a market, the team decided to change our name in January 2022 to APEX. The context behind this was…how will we inspire our teams to get to the top of the mountain even when we are tired and feel as if we have no more to give? We are struggling with agency usage, retention, lower reimbursement rates and the cluster rigor. The market has refocused and recommitted to growing leaders and inspiring their teams to turn their visions into reality.

On April 22, 2022 a team of our leaders rented a passenger van and drove 8hrs to Guadalupe Peak National Park. Guadalupe Peak is a rewarding, although strenuous, 8.5 mile round trip hike with a 3,000 foot elevation gain. It took a total of 8 hours to complete and was much more difficult than we anticipated. The following day we piled back up into the van and drove 8 hours back to New Braunfels. Squeezing into a passenger van after completing a grueling hike seems like it would be horrible but it was one of the best rides ever! We had fun blasting music, reminiscing about the death march we completed and just bonding in general.

This trip was one of the most amazing and transformational experiences I have ever had. Each of us came with a set of strengths and weaknesses and a varying ability to hike the course. We had some that could have run up the mountain (well, maybe just one clinical resource), some who walked at decent pace and some who had a very difficult time making it to the summit. The part that inspired me the most was how everyone helped each other out. We had stronger hikers in the back helping the ones who were struggling a bit. We had hikers leading the pack to encourage everyone to keep going and letting them know it was possible to make it to the top. Not one team member was left behind. The bonds and true friendships that were built that day are irreplaceable.

This experience can be tied to all of our goals as a market. The stronger operations help the struggling operations. The struggling operations are not scared to admit they are struggling and reach out to ask others for help. They are able to do this because they have relationships with each other that are built on trust. Every leader knows they will not be left behind. An activity we have decided to do as a market involves climbing peaks/hiking trails in Texas as a team. In essence, each climb is designed to challenge personal growth and ultimately help transform the way we serve our staff and residents.

Our question to you is…. What will your market’s challenge be? What “mountain” will you climb? If you come to TX and hike Guadalupe Peak, we will send you a medal. If you would like, we will come hike it with you!

If every market creates a challenge and a medal for those who complete it, we can motivate the clusters and teams to seek the medals together. Every adventure trip is priceless time with your team members having fun and hyper-focused to accomplish something extremely difficult. When they come back they are never the same again—what could this do for your buildings? Unity, loyalty, humility, perseverance, sacrifice…the list is endless in applications. Remember…the joy is in the journey!

APEX CHALLENGE:

  1. Pick your challenge (it has to be physical) and create excitement around it
  2. Create a medal
  3. Send pics of your challenge
  4. Update us on how your team responded (did this strengthen relationships? Etc)
    Move those mountains!! Conquer your challenges!! Build your teams!!
    CONTEST: Teams who submit a picture and a summary of how this impacted your team will be put into a raffle to win a prize!!

New Hire Coffee Connection

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By Denny Davis, Therapy Resource – Bandera – Arizona
Bandera East had its first New Hire Coffee Connection Meeting to help with retention, education, communication and culture. DOR Kathleen “Katie” Deichert, OT from Mission Palms, started this on the east side on April 29. We had three new hires (all new grads) and two current students (hopefully new hires in the future!) who attended, and it was a great success! They were very excited to meet other therapists and form relationships and connections with others within the organization.

We made it fun by playing two games to get to know each other, such as Left, Right, Center (which had a $15 grand prize!) and a Kahootz quiz covering a little bit of everything, including some background on Bandera, CAPLICO, billing, documentation and some general PDPM information to help introduce some different topics. The things they love about our company are the culture, the support and the feeling of belonging! We are doing a great job loving on our new staff and students!

I am very excited to be a part of the growth these new hires (and hopefully the students if they come back to us after they graduate) will go thru and see the great things they will bring to the company in the future as they learn, continue to develop their skill set, and become more confident therapists and leaders! I see great things coming!

Our next meeting in May will be with Matt Pecora at Chandler Post-Acute. 😊

Educational Nugget: Association Physical Activity and Risk of Depression

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Submitted by Jessica Foster, Therapy Resource, Bandera, Arizona
What are they saying? (**Definition of PA – Physical Activity)
The Message
The connection between physical activity and a lower risk of depression is well-known, but less is understood about the extent to which higher amounts of PA result in lower risks for depression. Researchers who analyzed the results of 15 studies involving more than 190,000 participants believe they’ve come closer to an answer: Yes, there is a dose-response relationship, they write, but it’s most significant (and predictable) at the lower end of the PA spectrum. Overall, they assert, if less-active adults in the studies had met current PA recommendations, one in nine cases of depression could’ve been prevented.

Why It Matters
Authors believe that establishing the dose-response relationship between PA and depression could be an important tool for health care providers and others in sharing the benefits of even modest amounts of PA, “especially to inactive individuals who may perceive the current recommended target as unrealistic,” they write.

More from the Study
Pinpointing the reasons for PA’s effects on depression were outside the scope of the study, but authors speculate that they could include neuro-endocrine and inflammatory responses, improved physical self-perceptions and more social interactions, and the effects of greater time spent in green spaces. The interplay of these factors needs more study, they add, particularly when considering how individuals with less access to green spaces and greater exposure to noise pollution may experience reduced mental health benefits.

Keep in Mind …
The study is not without its limitations, according to authors. Among them: PA levels were self-reported, data was limited at higher levels of PA, and data was lacking for analysis of demographic subgroups, including those from lower- and middle-income countries.

Giving Purpose to Life

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Submitted by Ryan Hough, Therapy Resource, Nebraska
Staci Slater, OT at Omaha Nursing & Rehabilitation, shared this great story about giving purpose to life and her support to further her patients’ education.

JG is a 27-year-old male who sustained a C3-4 SCI when he was 24 years old secondary to a MVA. This patient has a high school degree and enlisted in the U.S. Navy for three years following high school. He is residing in LTC following acute rehab. His goal is to return to his mother’s home following home modifications.

JG has a power TNS wheelchair that he is able to maneuver using head control. He enjoys playing X-Box using Quad Stick mouth control, and he has a head control mouse that he uses to control his phone and computer. His computer is also accessible with the use of Dragon Naturally Speaking in combination with the use of his head mouse.

When JG transferred to Omaha Nursing & Rehab, OT assisted the patient with high educational pursuit. OT assisted the patient with verifying options for financial assistance and education:
● Cleared out student loans
● Applied for FAFSA (financial assistance)
● Verified VA benefits
● Applied to the community college and was accepted
● Contacted community college accessibility department to be able to participate at a college level within the range allowed by physical limitation

JG had to take placement exams (completed online) and signed up for classes. He completed English class online and is now planning to take the math placement exam and continue with his pursuit of education. Through furthering his education, JG hopes to explore future career options.

Congratulations to Our New Keystone CTOs!

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Submitted by Jon Anderson, Senior Therapy Resource
Jennifer Henderson, OTR, DOR, Parklane West, San Antonio, TX
Jennifer Henderson, OTR, DOR at Parklane West, has been with our organization since 2016. Jennifer started out her career as a high school math teacher and then later decided to become an OT because she felt a calling to help older adults. During the Legend acquisition, she came over as a DOR from Sonterra Healthcare Center in San Antonio, Texas, and later decided to take a short break and become a full-time treating OT who helped several of our facilities in the San Antonio area. However, another opportunity landed in our laps with Parklane West, and Jennifer stepped up and once again became a DOR leading Parklane Therapy. Parklane started with a sleepy therapy program with only a few therapists, and today Jennifer has grown it to over 20 therapists/therapist assistants! Jennifer launched and trailblazed the Outpatient Therapy Program at Parklane before Outpatient was even a focus for the organization, and she has routinely mentored new DORs and helped other affiliates launch their outpatient programs. Jennifer has a passion for LTC programming and has worked with her team to launch our award-winning Abilities Care Approach dementia program with outstanding results impacting the facilities QMs and annual survey. Parklane is routinely and consistently in the top 1/3 of all therapy metrics within Keystone and has maintained a 5-star rating with QMs throughout the most recent year. Congrats, Jennifer, for reaching CTO!

Casey Murphy, PT, DOR, Healthcare Resort of Plano, TX
Casey has been with Keystone-affiliated facilities for a little over four years. He began his journey as a field therapy resource and moved into a DOR/resource hybrid role at the Healthcare Resort of Plano when an urgent need emerged. As he saw the potential and needs of the facility grow, he made the decision to solely take on the DOR role, and the results the facility has seen since he made this decision have been phenomenal. Casey’s development of systems for PDPM and Managed Care have helped the facility effectively manage their skilled short-term patients, and he frequently wears a Case Manager hat among many others. Casey’s embracement of Outpatient programming is what has really set them afire! What started out as just a few patients here and there has turned into an outpatient center that serves the entire community, and a viable line of business for HCR Plano. Casey takes the leadership development component of his role very seriously. He has started training multiple therapists in his facility on culture, financial and NetHealth basics, taking the time to help all those who express an interest in growth. He models Intelligent Risk Taking with his own professional development. Casey became certified in Geriatric Exercise, is Lymphedema certified, and is currently an NCS/EMG resident. Casey has presented on multiple market and global calls about outpatient development and leadership development. Even with his many hats, he takes the time to individually answer all questions from other therapists and DORs about outpatient and has helped many facilities in Keystone become successful. He is a true owner of his program, his team, and their results. Congratulations, Casey, for reaching CTO!

Quin Hall, SLP, DOR, Legend Oaks Healthcare, Paris, TX
Quin Hall started as a treating SLP at Legends Ennis, in Ennis, Texas, where he took their speech program to new heights in a few short months. He took the opportunity as the Director of Rehabilitation at Legend Oaks Healthcare and Rehabilitation in Paris, Texas, in November 2020. At the time he joined the team, there were only five therapists, and the department was struggling with culture, programming, and metrics. Now they are 13 strong and growing while being fiercely competitive in metrics and mentoring other buildings in how to recreate some of their programs. The culture that Quin has created in the Therapy department has spread throughout the entire facility. Therapy has truly become the heart of the building. He embraces CAPLICO by celebrating his team daily, loving them well, and pushing them to become the best versions of themselves. He also is the first to step up and take ownership when there are growth opportunities for himself. Quin has reached out to many of his cluster and market partners to share his secrets to the magic they have created with thriving group programs, a phenomenal long-term programming menu, and an incredibly strong speech program. You may have also seen him on the FlagPOST sharing speech group ideas, featured in the speech newsletter, or on the Long-Term Care Think Tank sharing about groups. Quin has taken on students and interns to both feed his staffing needs and pour back into his profession. He has an infectious spirit that keeps his team and facility motivated and excited to work. Congratulations, Quin, for reaching CTO!

Monica Sharp, PTA, TPM, Mesa Springs, Abilene, TX
Monica Sharp joined Wisteria Place in Abilene, Texas in October 2015 following a role in Fort Worth with pediatrics. She returned to Abilene to be near family and has been a part of our Keystone family in Abilene ever since. She jumped right in as a treating therapist assistant and embodied the culture at Wisteria to make a difference in the lives of our residents there. When the opportunity for a therapy program manager opened up at nearby Mesa Springs, Monica seized the moment and has been the TPM there since August 2018. When she took the helm of the team, there were seven therapists in the department. She has grown the team to 12 therapists and has led them to the top in the state for many therapy metrics. Under her leadership, they have significantly improved their long-term care programming, and the positive culture is apparent. Monica has worked closely with the ED and DON to lead Mesa Springs with zero-deficiency surveys, significant upswings in culture and care, and an overall sense of love throughout the building. Monica has demonstrated significant self-growth this year as well, looking inward to improve metrics and take ownership during difficult times. She helped the facility when the ice storm of 2021 left the building without power and water and has worked in Housekeeping and Nursing when COVID outbreaks threatened care. Monica has recently joined the managed care committee and has reached out to assist with education with her cluster and market partners. She has become a true owner of her department and their metrics while leading others to do the same. Congratulations, Monica, for reaching CTO!

Megan Wickliff, OTR, DOR, The Phoenix Post Acute Care, Texas City, TX
Allow me to introduce you to Megan Wickliff. There is no way to truly capture the true greatness of Megan within this paragraph, but I hope to provide a level of insight into the caliber of leadership she possesses. Megan has been the DOR of the Phoenix Healthcare and Rehab facility for over five years. This facility has come through many challenges, and Megan has stoically remained the pillar of strength for so many. She has made it her mission to make sure Therapy is never a contributor to the effects of having a silo. She crosses the invisible lines of duties and is always readily available to lend a hand in the Nursing, Social Services, Marketing, and Activities departments. There have been long periods of time that the facility may have been without an IDT, so Megan would take charge of leading meetings and carrying out any level of follow-up that was needed. To know Megan is to know a woman who does not have to say many words nor stand under the spotlight for her impact to be noticed. Her sheer level of humility and actionable service is beyond admirable. Megan is currently working on her Ph.D., as she has such a strong passion for learning and sharpening her level of leadership. I would be remiss to not mention that even though Megan leads the charge for several duties within her facility, she still has metrics worth bragging about. Congratulations, Megan, on receiving CTO; you are more than deserving of such a high honor!

Shayla Goode, SLP, DOR, Copperfield Healthcare & Rehabilitation, Houston, TX
Shayla Goode has been at the Copperfield facility for over four years. She first began her role as a staff SLP, shortly after she transitioned into the role of ADOR. Shayla would playfully say that she didn’t think she could ever be ready to fill a role as the DOR. The time came, and with a gentle push, Shayla accepted the position of DOR at the Copperfield facility. For those not familiar with this facility, I must share that they have been the facility to watch when it comes to managed care penetration in the Keystone East market. They have been the drivers for navigating efficient ways to manage the needs of those patients. Shayla has played a pivotal role in building such a strong foundational relationship with each of her case managers. She has led the charge of educating not only her Rehab team, but also the IDT about how to be quality partners with our case managers. I want to make sure I don’t diminish her other incredible accomplishments such as being a ranked department in lowest CPM, highest PNSD, highest productivity and consistently finishing in the top 4 for Keystone East Outpatient revenue. What speaks even louder than the metrics that I shared is the level of tenure she has with her Rehab team. Her team has continued to grow, and with great pride she shares that her turnover rate is incredibly low. Shayla knows the positive effects of leadership development, and that was a major goal of hers in 2021. She truly took the time to grow her ADOR, and she has redesigned the role to reflect the vision that she has for the future of the department. This is only the beginning of Shayla’s journey, and becoming CTO is an honor that is very well-deserved.

Congratulations to Our Newest SPARC Winner!

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Kathryn Russell, PT Student, AT Still University, Mesa, AZ — Grad Date: June 2022
Read Her Awesome Essay Below:
A spark in the lives of my patients — a metaphor appreciably open to interpretation. I guess I have asked myself a parallel question but framed in a different way: how will I make a meaningful positive impact on my patients that endures beyond their physical therapy encounter? Now, my education and training, while both instrumental in driving the principles I want to implement in my practice, do not act entirely to answer the question to its fullest, nor should they. My personal objectives that were not taught are the ones I believe make me stand out to patients, and maybe make me a spark in their lives, but it seems selfish to aim to be the spark in someone’s life. That implies that I chose physical therapy for me, rather than for others.

This is why I’ve included my own version of the question, slightly reframed. I don’t seek to be the sole reason someone improves, heals, or has less pain. My goal is instead that each patient discovers the value of taking on that responsibility for themselves even after they are discharged from my care. I’ll acknowledge that’s a cliché goal, and a lofty one at that. If there’s anything my education and training have taught me, though, it’s that the values of our profession have to be intricately weaved into the patient’s existing lifestyle for meaningful and persevering change to take place.

Making those connections with the patient to increase the likelihood of them assuming the responsibility for their own health should always start with education, combines movement, and finally always considers extraneous factors of healing.

I was taught in PT school the value of providing education to the patient, but I’ve always had the most passion about this piece anyway. This is the component I am most excited to write about to share with you, and the one I am always eager to incorporate in the clinic with patients. I’m good at being a student — I guess that’s why I’ve been in school for the last two decades without a break. Only recently, though, did I consider how often I am also offered the opportunity to be the teacher, as well. I take pride in being able to take full advantage of the opportunity to incorporate a dose of education about a patient’s injury/condition and about the body’s role in healing. The thing that makes it stick, and actually drives a patient to assume their health responsibility, is to limit medical jargon, and capitalize on the body’s resilience. This strategy makes it an accessible and positive experience, thus empowering them to want to learn more.

My goal is to act as the constant reminder that knowledge is power, the body is strong, and there is more than one correct way to journey through recovery. I do think this is an area that we have the opportunity to improve upon as a profession due to the current disappointingly standard practice to scare our patients into compliance and use outdated diagnostic terminology that actually enables kinesiophobia.

That brings me to my next key component of influencing an individual’s health responsibility: mixing in movement, and truly using it as medicine (not just because it sounds catchy). My guiding principles for this are nothing new; I did not reinvent the wheel. I aim to find activities the patient already likes to do, combine exercises into daily activities, and remind the patient how the exercise is relevant to them. They’re simple, and they are effective for serving the purpose of creating lasting change.

Education and movement are the two leading values in the profession of physical therapy that most practicing clinicians are aware of and using to some extent. However, if we do not consider the extraneous factors in people’s lives that guide not only their micro-level decision-making but also their healing experience as a whole, then we will fail our patients. Again, I think this is an area where I see room for improvement within our profession, and that I aim to change by at least incorporating it into my practice first. Essentially, I aim to seek out what else can we offer to patients to facilitate their healing. We must consider all the senses that are stimulated when a patient comes into the practice. What is the surrounding, what is the simplicity of accessing the clinic, what is the language that is used by the front office staff? Do these things create an atmosphere of healing? We cannot expect patients to heal in a vacuum of reality. If a patient doesn’t feel at ease, if they had difficulty finding the area or dealing with technology, or if they feel rushed or patronized, it will lend to their perception of their physical therapy experience. Whether we like it or not, we all subconsciously contribute to the narrative that drives our healing, positive or negative. So, it is a responsibility to consider everything that adds to that narrative.

The healing experience is different for everyone and I believe it is my responsibility as a physical therapist to adapt my treatment strategy to serve each patient best using these three core pillars. Understanding this at an individual level is the most effective way to create that spark that instills the health responsibility that contributes to lasting change. The physical therapist is a pawn in leading the patient to understand their healing, not the individual who cures them. All I am doing as their physical therapist is providing them the knowledge and direction to make informed decisions regarding their movement and self-care, and providing the space that facilitates their healing. I want my patients to see their whole physical therapy experience as the spark that ignited a passion for being the expert of their body — healing it, learning it, listening to it.

Special Focus Facility Graduation

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By Paul Emerson L. Baloy OTD, OTR/L, DOR, The Hills Post Acute, Santa Ana, CA
The Hills Post Acute was officially removed from the Special Focus Facility List as of January 14, 2022, as a result of improved compliance with federal regulations as documented in the findings from the recent recertification surveys and complaint investigations.

Special Focus Facilities are nursing facilities that have a not-so-good history of past surveys that were identified by the Centers for Medicare & Medicaid Services and were given an opportunity to improve their systems to better the care of the vulnerable elderly entrusted to them.

The Hills Post Acute had to successfully complete two intensive and comprehensive successive surveys. The building under the previous owner and management has been riddled with multiple complaints and poor past survey outcomes, placing the facility on that special focus list last year.

Our new management team was entrusted with this enormous and critical undertaking and, with the help of our cluster partners and resources, devised strategic plans to address problem areas and came up with multiple dynamic systems to cope with the complex and evolving needs of the building.

With the unwavering support and continued dedication of the facility staff to patient care, we finally graduated from that list, completing two successive surveys in record time with a remarkably low number of deficiencies.

This is a true testament to all our collaborative work toward a common vision of bettering the care of our residents:
This is such a huge win! A win that reflects the staff’s everyday effort and trust in our systems.
This is our story. This is our success.
A chapter in our lives that will be etched in the history of our building and of our residents.
Share this win. Share this story. Congratulations, Team Hills!
Thank you very much for all that you do.
Onward and upward… Dignifying post-acute care in the eyes of the world.

Tag Busters: Skin Integrity

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By Tamala Sammons, M.A. CCC-SLP, Senior Therapy Resource

F-Tag 686: Skin Integrity; Pressure Ulcers/Injuries

Surveyors will assess how a facility is doing based on the comprehensive assessment of a resident, and ensure that:

  1. A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and
  2. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

How can Therapy help be a partner to ensure the facility has a strong skin system? Start by asking a few questions:

● Is skin integrity and risk for pressure ulcers assessed on every Therapy evaluation? Should it be?
● Do therapy assessments include other risk assessments, i.e., tissue tolerance testing? Pain? Nutrition/Hydration? Incontinence?
● When OT is working on showers with patients, in addition to focusing on ADLs, do they assess the patients’ skin?
● How often does PT remove a patient’s shoes/socks to assess a patient’s feet?

There are a wide variety of clinical areas that Therapy can assess and treat to ensure residents have good skin integrity, reduce risk for pressure ulcers/injury, and actively treat wounds.

Pressure Points and Tissue Tolerance
An at-risk resident who sits too long in one position or is known to slouch in a chair has an increased risk for pressure ulcers/injuries. Elbow pressure injury is often related to arm rests or lap boards. Friction and shearing are also important factors in tissue ischemia, necrosis and PU/PI formation. PU/PIs on the sacrum and heels are most common.

● How often does Therapy assess for pressure points and tissue tolerance?
● Does Therapy assist with the completion of the Braden Scale? Your clinical partners would love the assist!

Positioning and Support Surfaces
Once the IDT identifies who is at risk, how do they determine the needed support surfaces, proper positioning and/or repositioning frequency? Do they take into consideration the individual’s level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort? Appropriate support surfaces or devices should be chosen by matching a device’s potential therapeutic benefit with the resident’s specific situation.

● How does Therapy engage in assessing the appropriate positioning and support surfaces?
● How often does therapy assess residents to ensure the recommended positioning and support surfaces are in place, still meet the needs for each resident, and provide reviews/updates of the resident care plan?

Active Wound Care
PT intervention for active wound care is appropriate when any of these exist: Necrotic material is present in the wound bed; the wound is a stage 3 or 4 pressure injury; the rehab potential is good to meet stated goals; and/or the wound has an impaired healing process.

● Do we have a physical therapist on staff who treats wounds?
● Are we up to date on all the various wound care interventions, such as: scalpel debridement; closed pulse irrigation; ultrasound MIST; and/or other modalities?

Incontinence
Both urine and feces contain substances that may irritate the epidermis and may make the skin more susceptible to breakdown and moisture-related skin amage.

● What is Therapy’s involvement with incontinence intervention?

Nutrition and Hydration
Adequate nutrition and hydration are essential for overall functioning. It is critical that each resident at risk for hydration deficit or imbalance, including the resident who has or is at risk of developing a PU/PI, be identified and assessed to determine appropriate interventions.

● Is SLP involved as part of Skin IDT?
● Is the Think Thin program in place?

Contractures
A resident with severe flexion contractures also may require special attention to effectively reduce pressure on bony prominences or prevent breakdown from
skin-to-skin contact. Some products serve mainly to provide comfort and reduce friction and shearing forces, e.g., sheepskin, heel and elbow protectors.

● What is Therapy’s role with contractures? How often is skin/skin hygiene assessed?
● Does Therapy have an active hand/skin hygiene program?
● How often does Therapy assess splints’ effectiveness for not only the contracture but also skin integrity?

Pain
The assessment and treatment of a resident’s pain are integral components of PU/PI prevention and management. Pain that interferes with movement and/or affects mood may contribute to immobility and contribute to the potential for developing or for delayed healing or non-healing of an already existing PU/PI.

● What therapy assessments are completed to determine any pain levels?
● Are modalities used for pain management?
● Is level of pain discussed during skin IDT meetings?

Training, Education and IDT Collaboration Resources

● Refer to chapter VIII page 82 of the RNA manual for information that can be used for training CNAs and/or RNAs on skin and positioning. https://portal.ensignservices.net/Departments/Clinical-Resource-Tools/Manuals/manuals Scroll down or type in the search Restorative Nursing Program Manual.
● Refer to the EPIC section of the portal https://portal.ensignservices.net/EPIC/skin for education, information, and other resources for an IDT approach for skin.
● Refer to the Pressure Ulcer/Injury Critical Element Pathway. This can also be found on the portal. https://portal.ensignservices.net/Departments/Clinical-Resource-Tools/CMS-Requirements-of-Participation/CMS-TOOLS/NEW-SURVEY-PROCESS/critical-element-pathways
● Refer to a variety of supportive POSTettes for additional information: Wound Care, Contractures, UI, UTI, Pain, Nutrition/Hydration.