How often should nursing home residents be turned to prevent sores? Every two hours!!!??? Right? Maybe not. Turning every two hours is the current standard of care in North Carolina. However, a new study was performed which challenged that standard. It is called the Turning for Ulcer ReductioN (TURN) study. It was performed by the University of Texas School of Nursing and funded by the NIH.
They studied moderate and high risk nursing home residents for pressure ulcers. They put these residents on a 2 hour, 3 hour and a 4 hour turning and positioning schedule and placed them on high-density foam mattresses. Their conclusion: there was no difference in the pressure ulcer incidence (2%) over three weeks of observation between these three groups. So, the new turn and positioning requirement may need to be every 4 hours not 2 hours. This will be great news for nursing homes as their staff is already working very hard with low staffing levels at most homes. Some residents or patients that are extremely bad shape may still need two hours based on one study in the SICU, however if these patients are turned every two hours the majority of wounds are preventable.
At first, I was almost shocked by these findings, as it destroyed my belief in the 2 hour requirement. However, when you really look at the implications of this study, it is even more troubling than before. There are three very important things to consider now:
1. Pressure ulcer incidence- the incidence of pressure sores was only 2%, and this study only included moderate and high risk residents. The lower risk residents were excluded. If this study shows that 4 hours turning only resulted in 2% pressure ulcers, how is it that nursing homes have an average of 11% according to their own reporting on Nursing Home Compare? The average nursing home has a pressure sore incidence rate that is 500% higher than what it should be if they just turned every 4 hours. So, the question is: how long are they leaving these residents unturned? I have had some family members tell me that they were in the room for six hours at a time and no one came in to turn residents. I thought that was just an isolated incident, but now I am not so sure. It appears that nursing homes with higher than 2% pressure sores may be leaving them unturned for LONG periods of time.
2. Severity (Stage) of these sores- the study consisted of almost one thousand residents. Not only did only 2% get pressure sores, all of these sores were superficial minor sores. Stage I or II only developed. These thousand residents developed, none, zero Stage III or Stage IV sores. This study is further prove that Stage III and Stage IV sores usually don't occur without serious neglect of a resident. Failure to turn and position for more than four hours, failure to keep the skin clean and dry, etc., must be causing these terrible wounds.
3. Documentation- the study showed that documentation was thoroughly performed in this study. The CNAs observed the skin on a regular basis. According to this study, this likely creates a measure of safety for these residents as it allows a check to prevent wounds from worsening without treatment. Documentation isn't just paperwork, it is a necessity. Also, what does this study suggest regarding turning and positioning in nursing homes? It suggested that their turning and positioning charting is false. I have always wondered how these residents keep getting Stage IV pressure sores that often kills the resident, and yet the CNAs are charting that they are turning the resident every two hours. The answer is that they didn't, they were just writing down that they did. I have had CNAs testify that they have seen other staff go into a break room or some other place and just "fill in the blanks" and not really provide the care. With only a 2% incidence rate and no Stage IIIs or IVs, these CNAs are falsifying their records and the residents are suffering for that.
While I am a nursing home abuse attorney, my main goal is provide information to families and nursing home staff regarding proper care in nursing homes. This study actually will change the way that I pursue nursing home cases. I will not longer be so focused on the two hour requirement. Instead, I will now to try figure out how bad it really was at that home.