Resident Develops Pressure Ulcer

1
Resident Develops Pressure Ulcer
and
A. Residents natural defenses against pressure
ulcer fail
C. Rescue processes fail
B. Primary prevention processes fail
Mobility
Compromised condition
Not avoidable
Avoidable
hygiene
nutrition
continence
hydration
circulation
2
B. Primary prevention processes fail
B1. Preventive measures not initiated
B2. Preventive measures initiated
Risk not assessed
Risk not communicated
Risk not appreciated
B2.2 Planned measures not executed
Recognized risk not acted upon
B2.1 Planned measures inadequate
Unintentional omissions
Intentional omissions (violations, goal
conflicts, unworkable procedures)
Plan/expectation not communicated
(Chronic) distractions
3
C. Rescue processes fail
C.1 Rescue not possible (?)
C.2 Rescue possible
Rapidly developing injury (?)
Undetectable or uncorrectable(?)
C.2.3 No response
C.2.2 Inadequate response
C.2.1 Impending pressure ulcer not detected
Detection procedures not adequate
Detection procedures not followed