LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

F Tag 314 309 Quality of Care Part 5 Assessment Treatment Pressure Ulcer





  • ASSESSMENT AND TREATMENT OF PRESSURE ULCER part 5 LEEDerGroup.com: KYDEX Pro Multi Podus boot with ambulation pad Prevent Mitigate Heel UlcersKYDEX PRO Multi Podus
    It is important that each existing pressure ulcer be identified, whether present on admission or developed after admission, and that factors that influenced its development, the potential for development of additional ulcers or for the deterioration of the pressure ulcer(s) be recognized, assessed and addressed (see discussion under Prevention regarding overall assessment and interventions). Any new pressure ulcer suggests a need to reevaluate the adequacy of the plan for preventing pressure ulcers.
    When assessing the ulcer itself, it is important to:
    • Differentiate the type of ulcer (pressure-related versus non-pressure-related)
    because interventions may vary depending on the specific type of ulcer;
    • Determine the ulcer’s stage;
    • Describe and monitor the ulcer’s characteristics;
    • Monitor the progress toward healing and for potential complications;
    • Determine if infection is present;
    • Assess, treat and monitor pain, if present; and
    • Monitor dressings and treatments.
    Three of the more common types of ulcers are pressure, vascular insufficiency/ischemia (venous stasis and arterial ischemic ulcers) and neuropathic. See Guidance to Surveyors at 42 CFR 483.25 (F309) for definition and description of ulcer types other than pressure ulcers.
    At the time of the assessment, clinicians (physicians, advance practice nurses, physician assistants, and certified wound care specialists, etc.) should document the clinical basis (for example, type of skin injury/ulcer, location, shape, ulcer edges and wound bed, condition of surrounding tissues) for any determination that an ulcer is not pressurerelated, especially if the injury/ulcer has characteristics consistent with a pressure ulcer, but is determined not to be one.
    It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. When a pressure ulcer is present, daily monitoring, (with accompanying documentation, when a complication or change is identified), should include:
    • An evaluation of the ulcer, if no dressing is present;
    • An evaluation of the status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking);
    • The status of the area surrounding the ulcer (that can be observed without removing the dressing);
    • The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example: increased redness or swelling around the wound or increased drainage from the wound); and
    • Whether pain, if present, is being adequately controlled.
    The amount of observation possible will depend upon the type of dressing that is used, since some dressings are meant to remain in place for several days, according to manufacturers’ guidelines. With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the pressure ulcer wound should be documented. At a minimum, documentation should include the date observed and:
    • Location and staging;
    • Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth; and the presence, location and extent of any undermining or tunneling/sinus tract;
    • Exudate, if present: type (such as purulent/serous), color, odor and approximate amount;
    • Pain, if present: nature and frequency (e.g., whether episodic or continuous);
    • Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (slough or eschar); and
    • Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate. Photographs may be used to support this documentation, if the facility has developed a protocol consistent with accepted standards33 (e.g., frequency, consistent distance from the wound, type of equipment used, means to assure digital images are accurate and not modified, inclusion of the resident identification/ulcer location/dates/etc. within the photographic image, and parameters for comparison).
    The staging system is one method of summarizing certain characteristics of pressure ulcers, including the extent of tissue damage. This is the system used within the RAI.
    Stage I pressure ulcers may be difficult to identify because they are not readily visible and they present with greater variability. Advanced technology (not commonly available in nursing homes) has shown that a Stage I pressure ulcer may have minimal to substantial tissue damage in layers beneath the skin’s surface, even when there is no visible surface penetration. The Stage I indicators identified below will generally persist or be evident after the pressure on the area has been removed for 30-45 minutes. The definitions for the stages of pressure ulcers identified below, are from the NPUAP and used with permission.34KYDEX PRO Multi PodusLEEDerGroup.com: KYDEX Pro Multi Podus boot with ambulation pad Prevent Mitigate Heel Ulcers
    • “Stage I? – An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters:
    o Skin temperature (warmth or coolness);
    o Tissue consistency (firm or boggy);
    o Sensation (pain, itching); and/or
    o A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.
    • “Stage II? – Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
    • “Stage III? – Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
    • “Stage IV? – Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.
    NOTE: If eschar and necrotic tissue are covering and preventing adequate staging of a pressure ulcer, the RAI User’s Manual Version 2 instructs the assessor to code the pressure ulcer as a Stage IV. These instructions must be followed for MDS coding purposes until they are revised. Although the AHCPR and NPUAP system for staging pressure ulcers indicates that the presence of eschar precludes accurate staging of the ulcer, the facility must use the RAI directions in order to code the MDS, but not necessarily to render treatment.
    Ongoing evaluation and research have indicated that pressure ulcers do not heal in a reverse sequence, that is, the body does not replace the types and layers of tissue (e.g., muscle, fat and dermis) that were lost during the pressure ulcer development. There are different types of clinical documentation to describe the progression of the healing pressure ulcer(s). The regulation at 42 CFR 483.20(b)(1), F272, requires that facilities use the Resident Assessment Instrument (RAI), which includes direction to describe the healing of the pressure ulcer(s)for coding purposes for the MDS: The RAI User’s Manual Version 2.0, instructs staff to identify the stages of pressure ulcer(s) by describing depth in reverse order from deepest to lesser stages to describe the healing or improvement of a pressure ulcer (e.g., a Stage IV becomes a Stage III and so forth. This has been referred to as “reverse staging? or “back staging?). Some clinicians utilize validated instruments to describe the healing of a pressure ulcer. Although such instruments are appropriate for making treatment decisions, they may not be utilized for coding the MDS. Until the MDS is revised, the present coding system (reverse staging) must be used for completion of the RAI.
    Clinicians may use the National Pressure Ulcer Advisory Panel – Pressure Ulcer Scale for Healing (NPUAP-PUSH) tool. The NPUAP always refers to a healed pressure ulcer as a healed ulcer at the deepest stage of its development (e.g., a healed Stage IV or a healing Stage IV). The NPUAP cautions that the tool does not represent a comprehensive pressure ulcer assessment, and other factors may need to be considered when selecting pressure ulcer treatment options.
    Since surveyors may encounter clinician’s notes in which the NPUAP-PUSH tool is used as part of the facility’s documentation protocol, the following description of the tool is provided. The NPUAP-PUSH tool documents pressure ulcer healing consistent with the healing process, describes a healing pressure ulcer in terms of three ulcer characteristics, and assigns a numeric value to the characteristics: length (cm) x width (cm), exudate amount, and type of tissue (closed with epithelium; new pink, shiny epithelial tissue; clean, pink or beefy red, shiny, moist granulation tissue; slough tissue; or necrotic, eschar tissue).
    The 1994 AHCPR Guidelines and current literature35 indicate that a clean pressure ulcer with adequate blood supply and innervation should show evidence of stabilization or some healing within 2-4 weeks. Evidence accumulating since 1962 indicates that management of wound exudate coupled with a clean, moist wound environment allows a chronic wound (e.g., pressure ulcer) to lay down healthy granulating tissue more efficiently.36, 37
    If a pressure ulcer fails to show some evidence of progress toward healing within 2-4 weeks, the pressure ulcer (including potential complications) and the resident’s overall clinical condition should be reassessed. Re-evaluation of the treatment plan including determining whether to continue or modify the current interventions is also indicated. Results may vary depending on the resident’s condition and interventions/treatments used. The complexity of the resident’s condition may limit responsiveness to treatment or tolerance for certain treatment modalities. The clinicians, if deciding to retain the current regimen, should document the rationale for continuing the present treatment (for example, why some, or all, of the plan’s interventions remain relevant despite little or no apparent healing). Pressure ulcers may progress or may be associated with complications such as infection of the soft tissues around the wound (cellulitis), infection of the bone (osteomyelitis), infection of a joint (septic arthritis), abscess, spread of bacteria into the bloodstream (bacteremia/septicemia), chronic infection, or development of a sinus tract. Sometimes these complications may occur despite apparent improvement in the pressure ulcer itself. The physician’s involvement is integral whenever significant changes in the nature of the wound or overall resident condition are identified.