For residents at risk (e.g., vulnerable residents) or who have a pressure ulcer, are any of the following observed?   

• If visible, is the wound covered with a dressing, and is drainage present on the dressing (document color/amount/type/odor)? 

• Is the resident positioned off the pressure ulcer? 

• Are pressure relieving devices observed (e.g., heel protectors, w/c cushion, padding between bony prominences)?  

• If so, are they used correctly? 

• Is the resident in the same position for long periods of time when in the w/c or bed (resident is not repositioned in chair at least every hour and in bed at least every two hours)? 

• If visible, does the resident’s pressure ulcer dressing have drainage (document color/amount/type/odor)? 

• If visible, is there redness or swelling? 

• Does the resident show signs of pain or discomfort?