Pressure Injury Prevention Audit

Audit template for evaluating pressure injury prevention practices, including Braden score assessment, turning schedule compliance, device-related skin checks, and offloading measures.

Risk Assessment and Documentation

• Braden score completed within required timeframe
  Braden Scale assessment is documented on admission or per facility policy for the current patient/resident.
• Braden score is current and reflects current condition
  Score has been updated after any significant change in condition, mobility, nutrition, perfusion, or device use.
• Risk level documented with prevention plan
  Braden risk level is linked to an individualized prevention plan or bundle in the chart.
• Skin assessment documented on this shift/day
  A focused skin assessment is documented for pressure-prone areas and any existing redness, breakdown, or device marks.

Turning and Repositioning

• Turning schedule is documented and visible to staff
  A repositioning schedule or turning plan is present in the care record or bedside communication tool.
• Repositioning completed within ordered or policy frequency
  Observed or documented turns match the prescribed frequency (for example, q2h or individualized schedule).
• Turning documentation is complete for the review period
  Turn times, positions, and any exceptions are documented without unexplained gaps.
• Patient tolerance or refusal addressed
  If repositioning was delayed or refused, the reason and follow-up actions are documented and communicated.

Device-Related Skin Assessment

• High-risk medical devices identified
  Devices such as oxygen tubing, masks, cervical collars, splints, catheters, or compression devices are identified as pressure risks when present.
• Skin under and around devices checked at required frequency
  Skin beneath or adjacent to devices is inspected per policy and documented for redness, indentation, or breakdown.
• Device fit and padding are appropriate
  Devices are secured without excessive pressure and padding/positioning protects bony prominences where indicated.
• Any device-related skin changes escalated
  New redness, blistering, or breakdown related to a device is reported and a corrective plan is initiated.

Offloading and Support Surfaces

• Heels are offloaded when indicated
  Heels are floated or supported so they are free from pressure when the care plan requires offloading.
• Pressure-redistributing surface in use as ordered
  Appropriate mattress, overlay, cushion, or specialty surface is in place for the patient/resident risk level.
• Bony prominences are protected from direct pressure
  Sacrum, elbows, ankles, and other pressure points are protected with positioning aids or padding as needed.
• Mobility and assistance level support offloading plan
  The patient/resident has the required assistance, devices, or reminders to maintain pressure relief measures.

Education, Escalation, and Corrective Actions

• Patient or family education documented
  Education on repositioning, skin checks, and pressure relief is documented when applicable.
• Staff notified of any deficiencies
  Any non-conformance identified during the audit is communicated to the responsible nurse or care team.
• Corrective action plan documented for failures
  A follow-up action, owner, and due date are documented for any failed critical item or repeated deficiency.
• Audit comments and observations
  Record any relevant observations, barriers, or unit-level trends identified during the audit.