Date of Graduation

Summer 8-11-2026

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

Kaiser cohort MSN capstone

First Advisor

Cathy Coleman

Second Advisor

Sara Horton-Deutsh

Abstract

Abstract

Problem

Hospital-acquired pressure injuries (HAPIs) remain a costly patient safety concern with increased morbidity and prolonged hospitalization. Inconsistent admission skin assessment documentation in a 24-bed overflow medical–surgical microsystem led to delayed wound identification and misclassification.

Context

A baseline needs assessment (n = 15) identified key barriers, including low nurse confidence utilizing Rover (mobile software application) and linking photos to the LDA (lines-drains-airway) in the electronic health record.

Intervention

A bundle of 6 components was tested over 12 weeks: standardization of the two-RN skin assessments within 8 hours of admission or transfer; optimization of Rover photo capture and LDA linkage; clarification of roles and escalation pathway; reinforcement of staff education; implementation of weekly audits; and facilitation of a unit-based escape room simulation.

Measures

Key metrics included rates at which mobile images were correctly linked to the LDA, and timely completion of the two-RN assessment. Present-on-admission documentation accuracy and monthly HAPI rates were monitored.

Results

The LDA linkage rate increased significantly from 6% to 29% for mobile images. Two-RN compliance reached 96%; HAPI counts trended toward zero. Simulation evaluation resulted in a self-reported 11-point gain in workflow knowledge and a 23-point increase in the “very comfortable” rating for the Rover Wound Photo workflow.

Conclusions

Compliance gaps are not always immediately apparent. Diagnosing which subprocess is underperforming before designing an intervention is critical to effective quality improvement. Simulation training produced the most significant outcome within the intervention bundle. Improving HAPI outcomes is complex and time-consuming, yet vital to achieve value and sustainability.

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