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42767257276465State logo added here. If not, delete text box00State logo added here. If not, delete text boxLicensed Nurse Competency Checklist-Skin Integrity/Pressure Ulcer CareName:______________________________ Title: ___________________________ Hire Date:_______________Skill AreaEvaluation(Check One)Method of Evaluation(Check One)D = Skills DemonstrationO = Performance ObservationW = Written TestV = Verbal TestVerification (Initials/Date)CompetencyDemonstrated/Meets StandardsNeeds Additional TrainingDOWVEvaluator complete Licensed Nurse Competency Checklist-Skin Integrity/Pressure UlcerDemonstrates ability to differentiate between a pressure ulcer and non -pressure ulcerVerbalizes areas at risk for pressure ulcersDemonstrates /verbalizes understanding of tissue toleranceDemonstrates ability to measure wounds accuratelyDemonstrates ability to stage ulcers.Knowledgeable with criterial for each stage including Kennedy UlcersLicensed nurse demonstrates documentation responsibilities for skin integrity pressure ulcersAssessment ProcessRAI ProcessCare Plan Development, Implementation and RevisionsCommunicationEducationEtc.Demonstrates and utilizes facility specific forms related to skin integrity/pressure ulcersDemonstrates / verbalizesunderstanding of resident preference, individualized resident care plan, interventions and goals Demonstrates proper MDS 3.0 Coding for Sections M as applicable.Demonstrates resident/resident representative teaching including but not limited to:RepositioningNutrition/hydrationTherapyTreatmentsPressure reducing surfacesSigns and symptoms and medication for painSigns and symptoms of infectionDescribes understanding of the Pressure Ulcer Critical Elements PathwayDemonstrates ability to coordinate the resident’s care and monitor the outcomes with hospice.Verbalizes process and documentation for resident refusal of careOther (Describe) Other (Describe)*I certify that I have received orientation in the above-mentioned areas.center0*Employee:______________________________________________________________Initials Signature Date00*Employee:______________________________________________________________Initials Signature Date-2857571755Evaluator/Trainer:______________________________________________________________Initials Signature Date00Evaluator/Trainer:______________________________________________________________Initials Signature Date(PLACE IN EMPLOYMENT FILE)ReferencesCenters for Medicare and Medicaid Services (CMS) State Operations Manual, Appendix PP. Guidance to Surveyors for Long Term Care Facilities: for Medicare and Medicaid Services (CMS): CMS 20078: Pressure Ulcer/Injury Critical Element Pathway: Nursing Skills Reference ManualsManufacturer’s Recommendations on equipment, adaptive equipment, supplies, etc.Wisconsin ResourcesWisconsin Administrative Code Chapter DHS 132 Nursing Homes 132.60(1)(b) Decubiti prevention. ................
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