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Wound Care & Pressure Injury Prevention Audit
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Audit of pressure injury prevention and wound care covering skin risk assessment, repositioning, support surfaces, nutrition, wound assessment, and documentation of unavoidable injuries.
NPIAP GuidelinesCMS 42 CFR 483.25(b)TJC PC.01.02.07AHRQ Pressure Injury Toolkit
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Risk Assessment
- Is a validated pressure injury risk assessment (e.g., Braden Scale) completed on admission and at defined intervals? *
- Is a head-to-toe skin inspection performed on admission and reassessed with changes in condition? *
- Are existing (present-on-admission) wounds documented to distinguish them from facility-acquired injuries? *
Prevention Interventions
- Are at-risk patients repositioned on an individualized schedule and turns documented? *
- Are appropriate pressure-redistributing support surfaces (mattresses, cushions, heel offloading) provided based on risk? *
- Are moisture, incontinence, and skin protection interventions implemented? *
Nutrition & Hydration
- Are patients screened for nutritional risk with dietitian referral for those at risk of or with pressure injuries? *
- Is protein, calorie, and hydration support provided consistent with goals of care? *
Wound Assessment & Treatment
- Are wounds staged and assessed (size, tissue, exudate, signs of infection) using consistent NPIAP terminology? *
- Is an individualized wound treatment plan established, reviewed, and revised based on healing progress? *
- For facility-acquired injuries, is an analysis performed to determine whether the injury was avoidable or unavoidable? *
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