Pressure ulcers remain one of the most common "never events" in care settings—harm that should be entirely preventable with good care. When pressure damage does occur, CQC inspectors look closely at documentation to understand whether prevention measures were in place and properly implemented.
According to NICE Guideline CG179, pressure ulcer prevention requires systematic risk assessment, regular repositioning, skin inspection, and appropriate equipment. Documentation provides evidence that these interventions are happening.
Documenting Repositioning
Repositioning (also called turning) is a cornerstone of pressure ulcer prevention. Documentation should include:
Repositioning Frequency
The care plan should specify repositioning frequency based on risk level:
- Very high risk (Waterlow 20+): Every 2 hours or more frequently
- High risk (Waterlow 15-19): Every 2-4 hours
- At risk (Waterlow 10-14): Every 4-6 hours
Document when repositioning doesn't happen at the planned time and why (e.g., resident declined, at appointment).
Documenting Skin Inspections
Skin inspections should be documented systematically, checking key pressure areas:
Key Areas to Check
- Sacrum (lower back/buttocks)
- Heels
- Hips/trochanters
- Elbows
- Shoulder blades
- Back of head (for residents who are bedbound)
- Ears (from oxygen tubing or positioning)
What to Document
Red Flag: Non-Blanching Erythema
If redness doesn't blanch when pressed, this indicates tissue damage has occurred (Category 1 pressure ulcer). Document immediately, escalate to senior staff, and intensify prevention measures.
Documenting Pressure-Relieving Equipment
When pressure-relieving equipment is in use, document:
- Type of equipment: Static mattress, alternating pressure mattress, cushion, heel protectors
- Settings: For alternating mattresses, document pressure settings and cycle time
- Date deployed: When equipment was first put in use
- Reason: Link to Waterlow score or clinical need
- Regular checks: That equipment is functioning (power on, settings correct, mattress inflated)
Documenting When Pressure Damage Occurs
If a pressure ulcer develops, immediate documentation should include:
- Date and time discovered: Who found it and during what activity
- Location: Precise anatomical location
- Category/stage: Using the NPUAP/EPUAP classification (1-4, unstageable, deep tissue injury)
- Size: Length, width, and depth in centimetres
- Wound bed description: Colour, tissue type, exudate
- Photograph: With resident consent, for baseline and monitoring
- Immediate actions: What was done (dressing, referral, repositioning plan change)
- Notifications: Family informed, GP notified, incident report completed
Remember that new pressure ulcers (Category 2 and above) may need to be reported to CQC as a statutory notification.
Common Documentation Failures
- "Position changed" without detail: What position? When exactly?
- "Skin intact" without observation: Did you actually look, or is this routine?
- Missing repositions without explanation: If the schedule wasn't followed, document why
- No link to care plan: Documentation should reflect what the care plan says should happen
- Delayed documentation: Recording hours later from memory is unreliable
- Only documenting problems: Document normal findings too—they prove monitoring is happening
Key Takeaway
Pressure care documentation isn't bureaucracy—it's evidence that care is being delivered. When a resident develops a pressure ulcer, the first thing reviewers will examine is whether repositioning and skin checks were happening as planned. Complete, contemporaneous documentation is your defence and your quality assurance.
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