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Skin Observation Protocolfor Delegating Nurses serving HCS
and DDA Clients
Jerome Spearman RN –HCS
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Agenda
• Client Experience
– CARE Assessment
– Nursing Triggered Referrals
• Referral Process• Skin Observation Protocol
• Scenarios
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Client Experience- Day 1
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Client Experience- Day 2-3
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Client Experience- Day 3-4
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11
What is a Pressure Injury?
“A pressure injury is localized damage to the skin and
underlying soft tissue usually over a bony prominence
or related to a medical or other device. The injury can
present as intact skin or an open ulcer/injury and may be
painful. The injury occurs as a result of intense and/or
prolonged pressure or pressure in combination with
shear. The tolerance of soft tissue for pressure and
shear may also be affected by microclimate, nutrition,
perfusion, co-morbidities and condition of the soft
tissue.”National Pressure Injury Advisory Panel and European Pressure Injury Advisory Panel.
(2016). Prevention and treatment of pressure Injuries: clinical practice guideline.
Washington DC: National Pressure Injury Advisory Panel.
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Bony Prominence Locations
12
Coccyx
area or tail
bone tip
area
ischial tuberosities
or (“sitting bones”)
Sacrum
Area
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The Hospital & DSHS Experience
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Undermining/ Tunneling
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6 months later...
Hos
pit
alD
SHS
(HC
S)A
rea
Age
ncy
on
Agi
ng
Phase
6 monthslater
Hospital Stay 1-28 days
Hospital Discharge Team Meets to
discuss next steps
AAA CM performs a Significant change
Introduces ADH option
Client declines, NeedsMet by CaregiverNo referral sent
Client at home With caregiver
Client is dischargedback home
Family alerts CM of hosp. visit
How is CM Identified of client hospitalization
How will the hospital determine clients
Medicaid Eligibility?
Is the CM apart of Discharge Planning
discussion
How & Who will introduce Nursing
Service option to client ?
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Assessment
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Comprehensive Assessment Reporting and Evaluation (CARE)
• Computerized client assessment
– Triggers Nursing Referral Indicators
• Skin Observation Protocol (Mandatory
Referral from CM)
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What are the Nursing Referral Triggers?
• Nursing Referral Indicators – Unstable or Potentially
unstable diagnosis– Medication Regimen
affecting plan– Nutrition status affecting
plan– Immobility status affecting
plan– Skin Breakdown or History– Skin Observation Protocol
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Care Plan Triggered Referrals
21
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SKIN OBSERVATION PROTOCOL & CASE MANAGER RESPONSIBILITIES
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What will trigger the Skin Observation Protocol?
• Highest Risk Indicators– Current pressure injury
– Quadriplegia
– Paraplegia
– Hemiplegia with cognition & incontinence issues
– Total Dependence in Bed Mobility
– Bedfast&/or Chairfast• Cognition problems
• Bladder/Bowel
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What are the Skin Observation Protocol Requirements?
HCS- Policy( LTC Chap 24) DDA Policy 9.13
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CASE MANAGER RESPONSIBILITIES
• Identify in CARE• SOP triggered
• Send referral for SOP and include all the other triggered referrals
• Document in CARE referral process
• Consideration• Does the client have a Pressure Injury?
• Is there a caregiver treating the pressure injury?
• Is the caregiver a professional or non professional?
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Non-Licensed vs Licensed
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CASE MANAGERS RESPONSIBILITIES
• Case Manager determines appropriate provider• Nurse Delegator
– clients who receiving delegation already
• AAA
• Nursing agency
• DDA Clients – Case Resource Managers will follow SOP Referral Tree– *Nurse Delegators may receive a referral if there is not a AAA
willing to do the assessment( Applicable to Region 1)*
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Referral Forms & Timeframes
From Case Manager to Nurse Delegator
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SOP REFERRAL FORM
HCS # 13-776
• Items 1-9; 14 – Basic Background Information
• Item 10-11– Referral Request Activity
• SOP with visit
– Activity Frequency
• Item 12- Care Triggered Referrals Reason for Request
• Item 13 Special Instructions• Confirmation of Receipt and
Acceptance of referral
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HCS# 13-776
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SOP REFERRAL FORM
DDA # 13-911
• Items 1-9; 14 – Basic Background Information
• Item 10-11– Referral Request Activity
• SOP with visit
– Activity Frequency
• Item 12- Care Triggered Referrals Reason for Request
• Item 13 Special Instructions• Confirmation of Receipt and
Acceptance of referral
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DDA #13-911
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Example HCS 13-776
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HCS 13-776
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HCS 13-776
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NURSE DELEGATORS RESPONSIBILITY• Accept referral—time frame (DDA-HCS)
HCS DDA
CM SEND REFERRAL FORM IN 2 BUSINESS DAYS
CM SEND REFERRAL FORM IN 2 BUSINESS DAYS
48 HOURS RESPOND TO REFERRAL RND HAS 1 DAY TO ACCEPT AND 2 DAYS SCHEDULE VISIT
5 DAYS RETURN DOCUMENTATION TO CASE MANAGER
5 DAYS RETURN DOCUMENTATION TO CASE MANAGER
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RESOURCES
Prevention Plans
Pictures
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Resources
https://www.dshs.wa.gov/altsa/home-and-
community-services/nursing-services
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Pictures
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Prevention Plans
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Pamphlets
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SOP SCENARIOS & NURSE DELEGATOR RESPONSIBILITIES
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What are the Skin Observation Protocol Requirements?
HCS- Policy( LTC Chap 24) DDA Policy 9.13
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Observation Not Required
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Exception Disclaimer
• Make Observation
• Complete Form 13-783 or 13-911
• Complete 13-780
Exception: If you determine that the non-
professional care being provided through the
prevention plan is inadequate or is not meeting the
needs of the client, a nurse must make an
observation visit and revise care plan, as
necessary.
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Scenario 1
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Scenario 1 Sample Documentation
Nursing Documentation must be sent back to CM to be uploaded into CARE
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Scenario 2
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Scenario 2 Sample Documentation
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Scenario 3
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Scenario 3 Documentation
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Scenario 4
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Scenario 4 Sample Documentation
• Document that the client declined observation
• Document reasons for declination
• Any relevant information from conversation
• If able to secure observation, follow Observation Required Steps.
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Observation Required
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Scenario 5
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Scenario 5
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Scenario 5Sample Documentation
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Scenario 5 Sample Documentation
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Scenario 5 Sample Documentation
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Form 13-780
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Form 13-783
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Observation Delayed
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Observation Delayed
a. Refer immediately to the nurse or Nursing Services
resources for an observation visit as soon as
possible, if HCS/DDA Social Worker or AAA Case
Manager is not a nurse;
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Questions?