The development of a facility acquired pressure ulcer brings with it both a financial impact to an institution and a performance or quality of care impact that may be reportable to state or government entities.
The utilization of a Root Cause Analysis (RCA) process may help a facility gain insight into the development of a pressure ulcer through a review of the timeline of events. This process is not intended for the analysis of all facility acquired pressure ulcers but rather for review of the development of a Stage III, Stage IV or sDTI. This review may also provide gap information indicating there may have been a deviation from the facility’s Pressure Ulcer Prevention and Treatment Guidelines. It may provide an opportunity for improvement in the process of the facility’s skin management program. NPUAP wants to emphasize that a Root Cause Analysis (RCA) is not intended as a punitive function but rather as a learning and growth opportunity for facility staff. The facility Risk Manager should direct the storage location of this type of document.
Please click HERE to view the RCA template.