Although facilities now have a resource to guide them in the prevention and treatment of pressure ulcers, the new guidelines may subject providers to more citations.

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ecently, I had dinner with a friend, an enterostomal therapy (ET) nurse who works in an acute care hospital with an affiliated long-term care facility. We discussed a survey with which she was involved. Unfortunately, neither she nor the director of nursing (DON) at the skilled-nursing facility (SNF) was aware of the new Centers for Medicare and Medicaid Services (CMS) pressure ulcer guidelines released on November 12, 2004. As we chatted about the circumstances, however, it seemed that the surveyor was not up to speed on the new rules either. The surveyor tried to cite the facility for an issue related to pressure relief, which my friend knew was unwarranted. She did some research and found the information that she needed to support the care rendered, proving to the surveyor that there were no infractions.
       Shortly after our conversation, I decided to write this article, since the aforementioned problem is probably repeating itself all over the country. In light of the awareness of pressure ulcers and the consideration that they are a national health problem with regard to the Healthy People 2010 initiative, Federal Tag 314 (Tag F314) has been revised with increased penalties for noncompliance.
       Nursing homes must prepare to more aggressively prevent and treat pressure ulcers as a result of recently released guidance from CMS. The pressure ulcer guidelines for CMS surveyors are different from previous ones, because they are evidence based and reflect current best practices. They explain assessment, prevention, and care practices in detail. Although CMS surveyors may now be more educated, and nursing homes now have a single resource to guide them in their prevention and treatment of pressure ulcers, the new guidelines may subject providers to more citations.

The Guidelines

       CMS has released new guidelines on the care and treatment of pressure ulcers for surveyors.¹ The guidelines provide definitions to distinguish between several types of skin ulcers. They explain investigative protocol to determine whether pressure ulcers were avoidable or unavoidable and are more specific about citations and deficiency categories. In addition, the guidelines contain specific instructions on how to document healing pressure ulcers on the Minimum Data Set (MDS), which still requires clinicians to incorrectly “back stage.” Also replaced is the text that surveyors had been using to cite facilities for infractions under Tag F314.
       What does this mean to the long-term care provider? There is no time to waste—you and your staff must learn all you can as soon as possible about the assessment, prevention, and treatment of pressure ulcers. Be ready before surveyors visit your facility with the new CMS guidelines in hand. Understanding and complying with these new CMS guidelines is the key to avoiding survey deficiencies and litigation. It is important to anticipate more aggressive investigation of pressure ulcers and higher severity for any deficiencies. A 1-size-fits-all approach to pressure ulcer prevention and treatment will not survive the surveyor’s scrutiny, and the likelihood of resultant serious deficiencies is high.
       The 2-pronged purpose of the new guidance is to ensure that SNFs prevent pressure ulcers unless they are clinically unavoidable and to check that staff members provide all the necessary treatments and services to help these ulcers heal if they do occur. Nursing homes that do not properly assess residents’ skin integrity on admission, do not identify pressure ulcer risk when appropriate, and do not update care plans to show they are monitoring progress are all at risk for a citation under Tag F314. The admission assessment is especially important. A comprehensive and vigilant assessment may identify pre-existing signs and symptoms, such as undue redness or edema, that can lead to an unavoidable full-thickness wound.

Guideline Overview

       Briefly, the guideline was revised to include the following information:
• Pressure ulcers can develop within a 2-hour period
• Skin assessment should occur on admission and weekly for 4 weeks
• Avoid cookie-cutter plans of care; facilities need to concentrate on residents’ risk factors and prevention, not just the Braden scale
• Advance directives will not void care related to pressure ulcers
• Staff training and knowledge of pressure ulcer care will be challenged.
       Skilled nursing facilities will be subject to more citations and, in some circumstances, higher severity in the citations. Following are possible citations, organized by level.
       Level 4—immediate jeopardy: A resident acquires a stage 4 avoidable pressure ulcer, or the facility fails to implement a comprehensive, individualized care plan for the treatment of pressure ulcers. A possible example is a resident is admitted with a stage 4 ulcer that worsens or shows no sign of healing, or a facility fails to follow multiple standards of pressure ulcer care or fails to keep stage 3 or 4 ulcers from becoming infected.
       Pressure ulcer infections may prove difficult to prevent. One example is Christopher Reeve, who likely had the best care and still developed a pressure ulcer. Despite top-notch treatment, it was reported that Reeve developed an infection and ultimately became septic, which caused a heart attack and subsequent death. Under these surveyor guidelines, SNF residents with the same risk factors as Reeve will have greater outcome expectations. Facilities are advised to consider broad-spectrum antimicrobial dressings, such as those containing ionic silver, to prevent these colonized wounds from developing into infection.
       Level 3—actual harm: The resident acquires a stage 3 avoidable pressure ulcer, or the facility fails to implement a comprehensive, individualized care plan for the treatment of pressure ulcers. Surveyors may cite for “actual harm” deficiency if a resident develops an avoidable stage 3 pressure ulcer or multiple/recurring stage 2 ulcers or if they find that the facility failed to implement a comprehensive care plan to treat a pressure ulcer.
       This could leave room for surveyor interpretation of the comprehensive care plan. For instance, a surveyor could tag a facility if he or she felt the staff did not turn the resident often enough or turned the resident at a time span of 2 hours and 15 minutes instead of within 2 hours. This is why facilities must update the 2-hour turning schedule and create a personalized schedule for everyone.
       Level 2: Facilities may be cited in this area if a resident experiences a stage 1 or 2 pressure ulcer that surveyors deem avoidable. Other cases for deficiencies include a SNF that does not properly address a resident’s risk for a pressure ulcer or staff who miss an element in the treatment plan of a resident who has an ulcer. Improperly addressing residents’ risks can result in avoidable pressure ulcers.
       Residents with pressure ulcers will be cited under Tag F314. However, SNFs will also need to address non-pressure ulcers, or they could be cited under Quality of Care Tag F309 (which has clarified the definitions of arterial, venous, and diabetic ulcers as well as other wounds). Surveyors may now cite SNFs for care related to ulcers not created by pressure under Tag F309.
       Under regulation 483.25, Quality of Care, each resident must receive—and the facility must provide—the necessary care and services to attain or maintain the highest physical, mental, and psychological well-being in accordance with the comprehensive assessment and plan of care. The intent of 483.25 is for the facility to ensure that the resident obtains optimal improvement or does not deteriorate within the limits of the resident’s right to refuse treatment, the limits of recognized pathology, and the normal aging process.
       Level 1: These citations do not apply to Tag F314, according to the guidelines. One of the stimulating additions to this updated CMS guideline is a list of extensive examples of what a facility must do or not do in order to become cited in a particular area. This is groundbreaking information that facilities should use to their advantage. If a facility has documentation that all the necessary steps were taken but it was still cited, it could proceed to arbitration to fight the citation based on its action, documentation, and CMS guidelines.

Updating your Protocols

The first step in getting up to speed is to examine your wound management protocols. Do they have the proper elements of the process of care of recognition—clinical skin assessment and use of a standardized tool, assessment/root cause analysis—involving the practitioner, treatment (prevention and management), and ongoing management and monitoring, which is an continuing process?
       With regard to assessment, pay particular attention to nutrition, hydration, and moisture. Summarize resident-specific evidence related to nutrition—for example, the severity of the resident’s nutritional compromise, rate of weight loss, or appetite decline. Also of prime importance is the individual’s prognosis and projected clinical course, along with his or her wishes and goals. Hydration is another assessment trigger. It is critical that each resident at risk for hydration deficit or imbalance be identified; the guidelines state that hydration needs to be addressed. Lastly, moisture has an impact on ulcer development and is specifically spelled out in the guidelines, which state, “Both urine and feces contain substances that may irritate the epidermis and make the skin more susceptible to breakdown. It may be difficult to differentiate dermatitis related to incontinence from partial-thickness skin loss (pressure ulcer). This differentiation should be based on the clinical evidence and review of presenting risk factors.”
       Therefore, we must be diligent in our skin care protocols and practices. A 3- or 4-pronged approach of cleanse, moisturize, protect, and nourish should be in place. Pay special attention to the type of barrier cream or ointment being used. Products containing zinc oxide (especially the invisible type) and the high-tech, newer silicone-containing protectants are superior and should keep incontinence dermatitis to a minimum. Also, products like cleansing cloths that contain a barrier help decrease steps and ensure that all residents are adequately protected. Another area of concern is support surface selection, both recumbent and seated surfaces. These measures can effectively alleviate pressure, shear, friction, moisture, and heat, addressing the extrinsic assaults on residents’ skin. Your skin and wound care providers can assist you in reaching your goals, so be sure to include them in your decisions.
       Risk management should first include identification of which residents are at risk and identification of which residents have ulcers. Then the practitioner should be involved to determine what underlying causes are not modifiable. Documentation should include assessment, findings, reasons for risk/ulcer, and whether risk factors are modifiable. The admission evaluation may identify pre-existing signs, such as “purple pressure ulcers,” or deep-tissue injury. It is essential that the resident and family understand the goals and probable outcomes. This understanding must be articulated and documented in addition to being countersigned by the responsible party.
       From there, the medical record must include expected outcomes, the plan of care, communication to staff that the plan of care is being carried out and periodically monitored, and changes in intervention if the treatment plan changes for any reason. Thorough documentation is a must.
       With regard to treatment, the guidelines state that if a pressure ulcer fails to show some evidence of progress toward healing within 2 to 4 weeks, the pressure ulcer, potential complications, and the resident’s overall clinical condition should be reassessed. Current literature² reports that all stage 2, 3, and 4 pressure ulcers are colonized with bacteria but may not be infected. Keep this in mind when performing the reassessment. It is imperative for the care plan to be carried out, the responsible practitioner to be notified if the wound is not healing, and the resident and/or responsible party to be aware of the plan and probable outcomes.

Education

       The 41-page revision to the Guidance to Surveyors is different from previous versions, because it explains assessment, prevention, and care practices in depth. It is as much educational as it is regulatory. This has both positive and negative consequences for SNFs. For instance, providers do not have to thumb through dozens of journals or references for the latest pressure ulcer prevention and treatment information. Conversely, surveyors are that much more educated.
       Take, for example, a nursing home whose protocol is to reposition residents every 2 hours—the industry norm. The new guidelines make a strong statement that some residents will need closer, individualized attention. If SNFs do not make consequent changes in care plans and practice, they should expect citations. The plan must be individualized based on the resident’s needs.
       All staff performing direct patient care should be knowledgeable about current best practices based on their responsibilities. For instance, a staff nurse should be able to assess a wound, identify the stage of a pressure ulcer, and recognize major risk factors for developing pressure ulcers as well as comorbid conditions that can increase susceptibility for pressure ulcers. They should also be cognizant of updated protocols and how they impact their duties.

Documentation

       CMS is up-front about the detailed level of documentation it expects from SNFs in the guidance. The guidelines state that minimal documentation needs to include:
• Location and stage of the ulcer
• Size of the ulcer and presence of any sinus tract
• Any drainage, including type, color, odor, and amount
• An assessment of pain that the resident may experience
• Color and type of tissue that comprise the wound bed
• Description of wound bed edges and surrounding skin.
       Then there is the case of the unavoidable pressure ulcer, which CMS outlines in detail in the surveyor guidelines. Facilities must take care to record everything about these ulcers, such as the risk factors they cannot modify and why those risk factors lead to an unavoidable ulcer. Although a high probability of an unavoidable ulcer may exist, you should still try to prevent it. When one occurs, regardless of a poor chance of healing, you still need to try to heal the wound.
       Additionally, everyone needs to keep abreast of the plan of care with nurses’ notes that document the progress, or lack thereof, for each intervention. The worst thing the facility can do is to merely write “goals met” on the care plan, because this does not tell staff—or the surveyor—anything about what was done. Continue to note the status of the ulcer in the care plan, even after it heals. SNFs need to make immediate changes to their prevention and treatment protocols regarding the care of pressure ulcers and other wounds. Moreover, using proper documentation can prevent a citation.

Scenarios

       Providers should be aware that Tag F309 now includes definitions of ulcers that are not related to pressure. The definitions clarify arterial, venous, and diabetic ulcers, as well as other wounds. If surveyors wish to cite a SNF for care related to an ulcer not created by pressure, they may use Tag F309. The bulk of the revised regulation, nonetheless, lies in the Tag F314. Here are a handful of the prominent features of the revamped Tag F314 guidelines in greater detail:
• Residents can develop a pressure ulcer in as little as 2 hours. This means that facilities cannot assume that if a resident gets a pressure ulcer on the day of admission, it was the previous caregiver’s fault.
• Though you will not abandon your Braden pressure ulcer assessment scores, you will not rely on them as heavily to determine pressure ulcer risk under the new system. Facilities should begin to concentrate on the risk factors a resident has and address them, regardless of whether the resident is at high risk for an ulcer.
• Just because a resident has advance directives does not alleviate the provider from having to care for the resident’s existing pressure ulcers. Advance directives only address the use of resuscitation; it is not an automatic refusal of all treatment. If a resident refuses treatment, document the evaluation and refusal of treatment, look for alternatives, report it to the medical director, and alert the family.
• Weight shifting—shifting a person’s weight off an area for 10 or 15 seconds—is ineffective, according to the surveyor guidance. Moving forward, do not cite this as an intervention in your care plan. This is the issue that caught my colleague off guard and consequently resulted in citation for her facility.
• Surveyors are going to focus on your staffing in terms of whether pressure ulcers would have been avoidable had there been more staff. There is no particular standard regarding staffing, however. This is a weak point of the guidance that will inevitably result in confusion.
• Surveyors may interview the long-term care staff in greater depth. They will expect staff to know what interventions were selected, why they were selected, and that they were based on current best practices. Nurses will not be able to refer surveyors to a “wound care nurse,” because every caregiver is required to know pressure ulcer care.
• More responsibility will reside with the medical director. It is recommended that she or he become intimately acquainted with the new guidelines and assist the facility in the development and implementation of policies and procedures for pressure ulcer prevention and treatment.
• Facilities should be conducting a skin assessment upon admission and then weekly for the first 4 weeks after admission. Most facilities will have to change their patterns of practice to do this.

Treatment

       Abandon wet-to-dry dressings, which are known to damage healthy granulation tissue and cause pain, discomfort, and bleeding. The guidelines point out that this archaic treatment modality should only be used in limited circumstances. Consider using more appropriate dressings, such as amorphous hydrogels, alginates, and polyacrylate and cellulose dressings. Such advanced technologies can provide moist wound healing, gentle, pain-free debriding, and better overall outcomes. Determine the needs of the wound by assessing whether it is wet or dry, is flat or has depth, is clean, or needs debridement. These findings will lead the clinician to the correct dressing and should be included in the protocol and plan of care. Other areas to focus on include evaluation of colonized versus infected wounds, the use of clean technique for cleansing, care and dressing changes, wound pain management, and seated and recumbent support surfaces.

Getting Started

       Getting started is easy. Download the new guidelines, review them, and then get busy. Pull all your resources together: your wound care team, including your wound, ostomy, and continence nurse or certified wound specialist, DON, medical director, and other industry partners.
       The long-term care industry now has some concrete information regarding its survey process. The old method was punitive and provided no concrete guidance. The new guideline is comprehensive and instructive. This is a significant difference, since the new guideline educates with the goal to determine if an identified pressure ulcer is considered avoidable, ascertain the adequacy of the facility’s interventions, and work to prevent and treat pressure ulcers. The ultimate goal will assist in enriching the level of pressure ulcer care and reducing the incidence of new pressure ulcers in long-term care.

Helpful Websites:

http://www.amda.com: Home of the American Medical Directors Association (AMDA), this site offers several resources related to pressure ulcers. Its Pressure Ulcers Clinical Practice Guideline takes practitioners and others through recognition, diagnosis, treatment, and monitoring of pressure ulcers in long-term care.

http:// www.npuap.org: The official site of the National Pressure Ulcer Advisory Panel (NPUAP) offers several resources, such as pressure ulcer prevention points, the NPUAP summary of clinical practice guidelines, and the Pressure Ulcer Scale for Healing (PUSH tool).

http://www.wocn.org: The homepage of the Wound, Ostomy and Continence Nurses Society (WOCN) offers access to updates on CMS, the patient safety goals from the Joint Commission on Accreditation of Healthcare Organizations, and its Guideline for the Prevention and Management of Pressure Ulcers.

http://www.ahrq.gov: At the official site of the Agency for Healthcare Research and Quality (AHRQ), one can access the AHRQ clinical practice guidelines, Pressure Ulcers in Adults: Prediction and Prevention and Treatment of Pressure Ulcers.