Recent CMS pressure ulcer initiatives will significantly affect long-term care. Is your facility ready?

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ressure ulcers remain a serious challenge in long-term care facilities. It is estimated that as many as 23.9% of long-term care residents have pressure ulcers.¹ The most recent federal prevalence rate found that the mean prevalence for long-term care facilities is approximately 9%.² Pressure ulcer development is often used as a core measure of quality care, because it is perceived as externally controlled.³ Therefore, healthcare providers can contribute to a large extent to the ulceration.
       However, both the increasing incidence and prevalence of pressure ulcers can be attributed to the residents’ acuity, comorbid conditions, and numerous pressure ulcer risk factors. Thus, a skilled nursing facility that has a higher incidence or prevalence rate is not necessarily providing poor care to its residents. Nonetheless, the US Centers for Medicare and Medicaid Services (CMS) remains quite concerned about the increasing rates of pressure ulcers in long-term care facilities. This article will review 2 important initiatives that were published late in 2004, which will significantly impact pressure ulcer care in long-term care facilities in 2005 and beyond.

Federal Tag 314—Pressure Ulcers

       On November 12, 2004, CMS released “Guidance to Surveyors for Long Term Care Facilities.”⁴ This regulation is used by both federal and state survey agencies to assess the quality of pressure ulcer care provided to residents in long-term care facilities. Although the Federal Tag 314 (Tag F314) regulation has not changed, the way that CMS interprets it has changed significantly.
       The regulation states, “A resident that enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable.” The intent of the regulation is to ensure that a resident living in a long-term care facility does not develop pressure ulcers unless his or her clinical condition rendered the ulcer unavoidable. Moreover, this is predicated on the long-term care facility providing adequate care and services to promote the prevention of pressure ulcer development; promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible); and prevent development of additional pressure ulcers.
       The interpretation of the regulation covers 21 pages and provides surveyors with common definitions, from pressure ulcers to undermining. Thus, it provides a common language that should be used by both surveyors and clinicians while surveying long-term care facilities. It should also be noted that throughout the document, there are ample references that justify components of the comprehensive prevention and treatment programs.

Pressure Ulcer Prevention

       The prevention section of the interpretative guidance strongly suggests that preventive measures must be individualized and monitored for their effectiveness. The first component of prevention, according to the interpretative guidance, is risk assessment. A series of risk factors is provided, although it is noted that the list is not exhaustive. Thus, the responsibility of identifying resident risk factors remains with the clinicians. A good discussion is provided on the relationship of pressure points, tissue tolerance, under-nutrition, hydration deficits, and moisture to pressure ulcer development.
       New to the guidance is a comprehensive discussion on residents’ rights and advance directives and their relationship to pressure ulcer prevention. Thus, residents do have a right to refuse pressure ulcer care. It is also noted that the presence of a “Do Not Resuscitate” (DNR) order does not negate implementing preventive measures. Concluding the prevention section of the interpretative guidance is a lengthy discussion on repositioning, support surfaces, pressure redistribution, and daily monitoring of patients at risk for pressure ulcer development.

Pressure Ulcer Treatment

       The treatment section of the interpretative guidance focuses on the importance of accurate assessment of pressure ulcers. Moreover, the ability of the long-term care facility to delineate between pressure ulcers and other chronic ulcers is critically important. Clinicians should not label a venous stasis ulcer a pressure ulcer, since the treatment trajectory may be very different. Further discussions are provided on ulcer characteristics (eg, pain, exudate type, and wound tissue type). The interpretative guidance continues to follow the staging system developed by the National Pressure Ulcer Advisory Panel. This staging system uses a 4-stage approach to classifying level of tissue destruction.
       The final part of the treatment section reviews how pressure ulcers heal and provides guidance on tools that have been used to monitor the healing of a pressure ulcer. There is ample discussion related to infection and pain associated with pressure ulcers, and the section concludes with a general review of dressings and treatments. It is noted, however, that the use of wet-to-dry gauze dressings or irrigation may be used appropriately in limited situations but that repeated use may damage healthy granulation tissue in healing ulcers and increase resident pain. The guidance promulgates that a facility should be able to demonstrate that the implemented treatment protocols are based upon current standards of care.

Investigative Protocol

       The implementation of the investigative protocol by the survey team is the most important aspect of the survey process. This protocol determines whether the pressure ulcer was avoidable or unavoidable. Moreover, it determines the adequacy of the long-term care facility’s interventions and efforts to prevent and/or treat pressure ulcers. For the survey process, CMS defines both avoidability and unavoidability. Both concepts are based on systematic implementation of the processes of care instituted by the facility.
       CMS defines avoidability and unavoidability as follows:
• Avoidability: The resident developed a pressure ulcer, and the facility did not do 1 or more of the following: evaluate the resident’s clinical condition and pressure ulcer risk factors; define and implement interventions consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; and revise the interventions as appropriate.
• Unavoidability: The resident developed a pressure ulcer even though the facility evaluated the resident’s clinical condition and pressure ulcer risk factors; defined implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of interventions; and revised the approaches as appropriate.

Compliance

       Through the observations, medical record review, care plan review, and interviews with clinicians, the survey team determines if the pressure ulcer was avoidable or unavoidable. If the facility is found to have been deficient, the surveyor must analyze the following elements to determine level of deficiency:
• Presence of harm/negative outcome(s) or potential for negative outcomes because of lack of appropriate treatment and care
• Degree of harm (actual or potential) related to noncompliance
• The immediacy of correction required.
       Once the 3 elements of deficiency have been determined, the survey team cites the facility at a particular level. The highest is level 4 (immediate jeopardy to resident health or safety). It is important to note, however, that a facility can be cited at level 4 without the actual presence of harm, impairment, or death to a resident.
       The survey team can cite at level 3 (actual harm that is not immediate jeopardy). This level could include the resident who is clinically compromised or a decline of the resident’s ability to maintain or achieve his or her highest practicable well-being due to the pressure ulcer.
The survey team can also cite the facility at level 2 (no actual harm with potential for more than minimal harm that is not immediate jeopardy). This level indicates that although there was noncompliance by the facility, it resulted in minimal discomfort and/or has the potential to compromise the resident’s ability to maintain his or her highest level of well-being.
       New to the guidance is the elimination of level 1 (no actual harm with potential for minimal harm). It is the belief of CMS that the development of any pressure ulcer constitutes more than minimal harm.

Nursing Home Quality

       Since 1965, CMS has held long-term care facilities accountable for assuring quality care for the millions of residents who require nursing home placement. One method of assuring quality care is through the survey process. As previously discussed, the revised interpretative guidance should change the way clinicians provide care for residents at risk for, or with existing, pressure ulcers.
       Another method for improving the care provided to residents in long-term care facilities is through quality improvement. To this end, in December 2004, CMS released a report noting that pressure ulcers remain a problem in long-term care facilities. One goal that CMS has set in the Government Performance and Results Act (GPRA) is a reduction in the number of pressure ulcers in nursing homes.⁵ For 2004, the pressure ulcer goal was 8.9%. Although the optimal goal for pressure ulcers is unclear, CMS remains steadfast in its determination to significantly reduce the current rate.
       To help long-term care facilities reduce their pressure ulcer rates, CMS released the Statement of Work for the 8th Quality Improvement Organization (QIO) Contract Cycle in December 2004.⁶ QIOs receive federal contracts to work with long-term care facilities, home health agencies, hospitals, and other healthcare agencies to improve care to Medicare and Medicaid recipients. Each state has a QIO. For the first time, the 8th Statement of Work has identified pressure ulcers in long-term care facilities. Thus, in 2005, each state will develop and initiate quality improvement projects specifically designed for long-term care facilities to reduce overall pressure ulcer rates throughout the US.

Conclusion

       Pressure ulcers in long-term care facilities remain on the radar of CMS. Through the revision of F314 Interpretive Guidance to Surveyors and the QIO 8th Statement of Work, CMS is sending a strong message that it intends to reduce pressure ulcers in long-term care facilities either through penalties or quality improvement. In 2005, long-term care facilities will have a choice of how to reduce their rates, but either way, CMS will be watching.