Nursing & Healthcare Directories on: The Nursefriendly
Pressure Ulcers: "Avoidable" versus "Unavoidable"
By Jill Thomas RNC, LNC, LNHA, CWCN

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It is estimated by some experts that only a small percentage of pressure ulcers, perhaps as low as two percent, are unavoidable. The outcome of litigation can often depend upon successfully defining avoidable versus unavoidable. Although attempting to define these two opposing terms is often confusing and difficult, the Health Care Financing Administration (HCFA) has provided some direction. HCFA has advised state and federal surveyors that the following steps should have been in place in order to ascertain if a decline was unavoidable:

1. Had an assessment been competed?
2. Did the assessment identify risk factors for the deterioration?
3. Did the care plan address the risk factors?
4. Was the care plan implemented well and consistently across all shifts?


If any of these steps are missing and a patient/resident has negative outcomes, it is pretty safe to say that a decline may be determined to be avoidable.

With these four items in mind, when reviewing a medical record for pressure ulcers ask yourself the following types of questions.

A. When was the pressure ulcer first identified?
If the first indication of a pressure ulcer is noted 3 days after admission to a Long Term Care facility, investigate the activity of the client 2 weeks prior to admission. Evidence of tissue destruction may take up to 14 days to become apparent. For example, did the client have recent surgery? A person lying on an operating table or an emergency room cart for several hours, without appropriate surface support, may have already developed the beginning of tissue destruction.

B. Was the clients nutritional status adequate and monitored appropriately?
The nutritional component for prevention and treatment of pressure ulcers is paramount in         any successful protocol.

C. Was the Care Plan specific and the actual treatment plan followed accordingly?
Did the facility staff first identify at stage I/II and treat appropriately before it became a         stage IV or, did they identify at a stage III and allow to progress to a stage IV?

D. Was the treatment consistent?
Was the pressure ulcer on the coccyx and the facility had an appropriate support surface on the clients bed, turning the client every 2 hours and keeping clean and dry but, the client sat up in chair for long periods without a preventative cushion and position changes?


Jill Thomas RNC, LNC, LNHA, CWCN

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Created on August 5, 1999

Last updated by Andrew Lopez, RN on Monday, February 28, 2011


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