Date of Graduation

Summer 8-5-2020

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Dr. Nancy Taquino

Second Advisor

David Ainsworth

Third Advisor

Leisel Buchner



Problem: Inaccurate and incomplete pressure injury (PrI) assessment and documentation leads to inaccurate reporting of PrI quality reporting measures to the Centers for Medicare and Medicaid Services. Inaccurate, incomplete documentation of pressure injuries and wounds adversely affects the quality of care, financial reimbursement, and hospital reputation as well as increasing the risk of litigation to medical providers. Barriers to accurate and complete documentation by the nurses were inaccuracy in identification of PrIs Stage 1 or greater and knowing what and where to document the information in the electronic medical record.

Context: This quality improvement project attempted to improve nurse admission skin assessment and documentation skills in a 48-bed inpatient rehabilitation hospital (IRH). The IRH is a regional referral center for 22 hospitals in the health care system. They are a specialty unit caring for persons who are at high risk of developing pressure injuries due to their diagnoses of acquired brain injuries, strokes, spinal cord injuries and other neurological disorders.

Interventions: The interventions for this project were the development and implementation of an interactive wound assessment education program and wound/PrI documentation algorithm.

Measures: A bundle of three measures included accurate identification of PrI’s, complete documentation on the Shift Rehab Flow Sheet, and the Wound Flow Sheet. The medical records of 100% of newly admitted patients were reviewed for accurate identification and completeness of wound and PrI documentation, as verified by 2 RNs, and confirmed by the Certified Wound Ostomy Continence nurse’s documentation.

Results: The overall goal of this quality improvement project was to have complete, accurate identification and documentation of 80% of pressure injuries by the nurse at the point of the patients admission to the rehabilitation unit. This quality improvement project resulted in an increase in accurate and complete pressure injury identification and documentation to 100% for the past five months. Documentation for non-pressure related wounds rose from a baseline of 20% to 78% over a 9-month period. Using Improvement Science and Evidence Based Practice that included the implementation of an interactive education program, and the use of a Wound Documentation Algorithm, a significant improvement was seen in this units accuracy and completeness of documentation.

Conclusions: In our environment of value-based payment and focus on patient-centered care, it is essential that nurses are knowledgeable and can competently assess and accurately document and treat pressure injuries in a timely manner. The avoidance of litigation costs and potential financial penalties imposed by regulating agencies such as the Centers for Medicare and Medicaid Services, is well worth the time and investment of this quality improvement project for the patients, nurses and IRH.