Pressure Ulcer Prevention in Hong Kong Care Homes

What a pressure injury is, and where a care home meets it

A pressure injury is localised damage to the skin or the tissue underneath it, caused by pressure, or by pressure combined with shear, and it usually appears over a bony prominence, although the Elderly Health Service notes that it can also be related to a medical device or another object. The same page states the mechanism in one sentence: when a localised part of the body is under continuous pressure, the blood supply to that area is hindered, and a pressure injury develops as a consequence.

The service names the residents most at risk, and the list is short: those who are chronically ill and bed-bound, those who are incontinent of urine or faeces, and those who are overweight or underweight. The sites follow the anatomy. The Department of Health wound care guidance names the sacrum and the ankles among the prominent bony areas that are prone, and it describes a pressure sore as common among people who are bedridden, caused by persistent pressure, friction and moisture.

The two mechanisms, and the interval that interrupts them

Pressure is the first mechanism and shear is the second. Paragraph 12.4.2 of the Code of Practice for Residential Care Homes (Elderly Persons), issued under the licensing scheme for residential care homes, requires a home to assist bedridden residents in changing their positions regularly, and to help keep skin and clothes clean and dry so that skin is not in contact with sweat or excreta for a long time, which the Code says can lead to breakage, infection or pressure injuries.

The published interval is specific. The Centre for Health Protection guidance for residential care homes for the elderly, fourth edition, September 2025, states at section 4.5.3 that a home should assist a bedridden resident to change position at least once every two hours, avoid friction or impact between the body and the bed when the resident is moved, and consider pressure-relieving aids such as an air mattress. The Elderly Health Service uses the same figure and adds the seated case: where a chair-bound older person has the upper body strength, it suggests changing posture every thirty minutes by pressing on the arms to lift the body for about ten seconds.

Technique carries as much of the load as the timetable does, which is why the same DH guidance pairs the interval with a transfer instruction: avoid friction between the body and the bed during lifting and transfer, because that friction is one of the ways the tissue is loaded. A resident who is dragged up the bed has been moved on schedule and still been exposed.

The skin check, and what is not a care worker's decision

The DH guidance written for carers working in an elderly home places the observation where the work already happens, during bathing, diaper changing, position turning and wound care by the Community Nursing Service. Health workers should regularly inspect the skin condition of high-risk residents, meaning those who are frail, immobile, incontinent or bed-ridden, with special attention paid to the prominent bony areas. Where the skin is red or a blister is seen, the service advises more frequent turning and appropriate wound care, and it states that if a wound infection is observed, medical treatment should be sought as soon as possible.

The second half of that sentence is the boundary. Deciding what a red area means, whether it is a pressure injury at all, and how far it has progressed is a clinical judgement, and the staging system published by the National Pressure Injury Advisory Panel describes the categories a nurse or doctor uses rather than a set of labels for a care worker to apply. What a care worker contributes is the observation, reported in the same shift, and the record of what was seen and when.

This article therefore gives no wound care instruction and names no dressing or medicine. Anything applied to broken skin is decided by the nurse or doctor treating that resident, and a care worker asked to carry out a dressing should be working to a written plan from that clinician, not from a general guide.

Recording the turn, so the schedule can be shown rather than recalled

Paragraph 12.5 of the Code of Practice requires the Personal Health and Nursing Record kept for each resident to include special nursing care needs and nursing records, and it names the prevention of pressure injuries among the examples it gives, alongside incontinence care and the use of feeding or urinary catheters. A home that writes the schedule down as it happens has the evidence before anyone asks for it.

For a wound that already exists, the DH wound care guidance recommends assessment, evaluation and documentation weekly or every two weeks, and it sets out what that record is expected to carry: the cause of the injury, medical history, the location of the wound, its condition in terms of colour, size, depth, secretion and infection, pain intensity and the resident's nutritional status. That is a nursing record rather than a care worker's note, and the two should not be blended in the same column of a form.

The habit that makes this workable is the one described in care home documentation: write at the point of care, keep one version of the truth, and let the monthly review be a query rather than a search through three shifts of handwriting.

What inspection finds, what it means, and who acts next

The table below pairs what a skin inspection typically finds with the way the same finding is described in the published staging system, and with the role that acts on it. The middle column repeats a published classification, attributed to the National Pressure Injury Advisory Panel, and it is not a label for a care worker to apply.

One further category sits outside the table. The panel states that a pressure injury on a mucous membrane cannot be staged at all, which is a reminder that the assessment belongs to the clinician rather than to the person who first notices the change.

Moisture, continence and nutrition as parts of the plan

Moisture is the factor most easily left out of a conversation that is framed around turning. The Elderly Health Service advises keeping skin clean and dry, changing napkins frequently to reduce the risk of skin infection in residents who are incontinent, keeping clothing and bed linen clean and dry, and avoiding heavy objects such as a hot water bottle or folded bedding lying over the body. The CHP guidance states the same requirement in institutional terms, asking a home to help residents keep skin and clothes clean and dry so that skin is not in prolonged contact with sweat, urine or faeces.

Nutrition is not a soft measure either. The service advises a nutritious, high protein diet, giving meat, eggs, milk and beans as examples, to keep skin healthy, and adequate nutrition intake is one of the principles the DH wound care guidance lists for supporting healing. Movement belongs in the same paragraph: the CHP guidance tells homes to encourage residents to exercise regularly to increase physical activity and help their circulation, and the Elderly Health Service adds active or passive stretching for residents who cannot move themselves.

Equipment sits alongside all of it rather than replacing it. The DH tells carers to consult health professionals about pressure-relieving devices and names heel protectors, wedge pillows and air mattresses. That instruction is also where the equipment question belongs: which mattress, which boot and how often it is checked is a decision made with the nurse or the resident's clinician, not chosen from a catalogue.

Where the clinical line sits, and who a care worker escalates to

The Code of Practice draws part of the line in staffing terms. Chapter 11 provides that a home must not employ anyone as a health worker unless that person is a registered health worker, and paragraph 11.2 lists the duties of that role, including the provision of dressing for wounds or pressure injuries of residents. That is the duty the Code assigns to the registered role, which is why the dressing sits on one side of the line and the observation on the other.

The escalation route should therefore be short and written down. A care worker who sees a change reports it to the nurse in charge during the same shift. The nurse assesses the skin, decides the plan, and owns the record and any wound care. Where infection is suspected or a wound is not healing, the DH guidance says medical treatment should be sought as soon as possible, and a suspected wound infection is the point at which an observation stops being routine. For a resident living at home, the same guidance notes that relatives can be shown how to bring the person to an outpatient clinic for dressing as instructed by the doctor, and that a frail or immobile client can apply for the Community Nursing Service at a follow-up consultation.

None of this is a diagnosis, a dressing choice or a substitute for a professional assessment. Where a resident needs a clinician, only a clinician can say what the damage is. The staffing arithmetic behind a two hourly schedule, which decides whether the schedule is physically possible on a given shift, is set out in care home staffing ratios in Hong Kong, and the companion question of what a mealtime looks like for a resident who has trouble swallowing is covered in dysphagia and mealtime safety.