ORG. SYSTEMS & QUALITY LEADERSHIP TASK 1 1

Organizational Systems and Quality Leadership
Task 1
Stephanie N. Campbell
000499473
Western Governors University

ORG. SYSTEMS & QUALITY LEADERSHIP TASK 1 2

Organizational Systems and Quality Leadership Task 1

A. Nursing Sensitive Indicators In this given scenario, there are multiple nursing sensitive indicators present including pressure ulcer prevalence, restraint prevalence, and skill mix. (Montalvo, 2007) The most prevalent one for me was pressure ulcer prevalence. Yes, in this case, the pressure ulcer was likely secondary to restraint use, so these tie in together, but pressure ulcers overall are easy to prevent using proper turning and repositioning patients, even while restrained. When the patient’s daughter asked the CNA about the “red spot” on her father, the CNA shouldn’t have been lackadaisical in responding that it would “go away when he gets up”. Redness is the first sign of a pressure ulcer and can develop quickly, especially in someone who is more or less bed bound. This should be addressed as soon as possible by the CNA, either by reporting it to the RN or simply doing what is within her scope to prevent this from worsening. Regardless it needs to be documented to stay on top of the issue. As for the restraint use, the daughter being present presents a perfect opportunity for a trial release as she is at the bedside and wants safe care for her father. Instead of placing the patient back on his back to further lead to a pressure ulcer and placing him back in restraints, the daughter could have been educated on the trial release and the patient even sat in a chair with a tether alarm if needed. This would decrease the risk of pressure ulcers and restraint use. Most facilities I’ve worked in have had protocols in place for restraint use and the