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Risk Assessment and Documentation

Braden score completed within required timeframe critical (required)

Braden Scale assessment is documented on admission or per facility policy for the current patient/resident.

Yes No N/A

Braden score is current and reflects current condition critical (required)

Score has been updated after any significant change in condition, mobility, nutrition, perfusion, or device use.

Yes No N/A

Risk level documented with prevention plan

Braden risk level is linked to an individualized prevention plan or bundle in the chart.

Yes No N/A

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.

Yes No N/A

Turning and Repositioning

Turning schedule is documented and visible to staff critical (required)

A repositioning schedule or turning plan is present in the care record or bedside communication tool.

Yes No N/A

Repositioning completed within ordered or policy frequency critical (required)

Observed or documented turns match the prescribed frequency (for example, q2h or individualized schedule).

Yes No N/A

Turning documentation is complete for the review period

Turn times, positions, and any exceptions are documented without unexplained gaps.

Yes No N/A

Patient tolerance or refusal addressed

If repositioning was delayed or refused, the reason and follow-up actions are documented and communicated.

Yes No N/A

Device-Related Skin Assessment

High-risk medical devices identified critical (required)

Devices such as oxygen tubing, masks, cervical collars, splints, catheters, or compression devices are identified as pressure risks when present.

Yes No N/A

Skin under and around devices checked at required frequency critical (required)

Skin beneath or adjacent to devices is inspected per policy and documented for redness, indentation, or breakdown.

Yes No N/A

Device fit and padding are appropriate

Devices are secured without excessive pressure and padding/positioning protects bony prominences where indicated.

Yes No N/A

Any device-related skin changes escalated

New redness, blistering, or breakdown related to a device is reported and a corrective plan is initiated.

Yes No N/A

Offloading and Support Surfaces

Heels are offloaded when indicated critical (required)

Heels are floated or supported so they are free from pressure when the care plan requires offloading.

Yes No N/A

Pressure-redistributing surface in use as ordered critical (required)

Appropriate mattress, overlay, cushion, or specialty surface is in place for the patient/resident risk level.

Yes No N/A

Bony prominences are protected from direct pressure

Sacrum, elbows, ankles, and other pressure points are protected with positioning aids or padding as needed.

Yes No N/A

Mobility and assistance level support offloading plan

The patient/resident has the required assistance, devices, or reminders to maintain pressure relief measures.

Yes No N/A

Education, Escalation, and Corrective Actions

Patient or family education documented

Education on repositioning, skin checks, and pressure relief is documented when applicable.

Yes No N/A

Staff notified of any deficiencies

Any non-conformance identified during the audit is communicated to the responsible nurse or care team.

Yes No N/A

Corrective action plan documented for failures

A follow-up action, owner, and due date are documented for any failed critical item or repeated deficiency.

Yes No N/A

Audit comments and observations

Record any relevant observations, barriers, or unit-level trends identified during the audit.

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Run: Pressure Injury Prevention Audit

Risk Assessment and Documentation

Turning and Repositioning

Device-Related Skin Assessment

Offloading and Support Surfaces

Education, Escalation, and Corrective Actions

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