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 2 Pressure Sores





  • F314 (Rev.4, Issued 11-12-04, Effective: 11-12-04, Implementation: 11-12-04) §483.25© Pressure Sores
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  • Based on the Comprehensive Assessment of a resident, the facility must ensure that:
    (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and Intent: (F314) 42 CFR 483.25©
    The intent of this requirement is that the resident does not develop pressure ulcers unless clinically unavoidable and that the facility provides 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.
    NOTE: Although the regulatory language refers to pressure sores, the nomenclature widely accepted presently refers to pressure ulcers, and the guidance provided in this document will refer to pressure ulcers.
    Definitions are provided to clarify clinical terms related to pressure ulcers and their evaluation and treatment.
    • “Pressure Ulcer?- A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s).1 Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers.
    • “Avoidable/Unavoidable? Pressure Ulcers
    o “Avoidable? means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident’s clinical condition and pressure ulcer risk factors; define and implement
    interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.
    o “Unavoidable? means that the resident developed a pressure ulcer even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that
    are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.
    • “Cleansing/Irrigation?
    o “Cleansing? refers to the use of an appropriate device and solution to clean the surface of the wound bed and to remove the looser foreign debris or contaminants in order to decrease microbial growth.2
    o “Irrigation? refers to a type of mechanical debridement, which uses an appropriate solution delivered under pressure to the wound bed to vigorously attempt to remove debris from the wound bed.3
    • “Colonized/Infected? Wound 4, 5
    o “Colonized? refers to the presence of bacteria on the surface or in the tissue of a wound without the signs and symptoms of an infection.
    o “Infected? refers to the presence of micro-organisms in sufficient quantity to overwhelm the defenses of viable tissues and produce the signs and symptoms of infection.
    • “Debridement?- Debridement is the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process. 6, 7, 8
    Various debridement methods include:
    o “Autolytic debridement? refers to the use of moisture retentive dressings to cover a wound and allow devitalized tissue to self-digest by the action of enzymes present in the wound fluids.
    o “Enzymatic (chemical) debridement? refers to the topical application of substances e.g., enzymes to break down devitalized tissue.
    o “Mechanical debridement? refers to the removal of foreign material and devitalized or contaminated tissue from a wound by physical rather than by chemical or autolytic means.
    o “Sharp or surgical debridement? refers to removal of foreign material or devitalized tissue by a surgical instrument.
    o “Maggot debridement therapy (MDT)? or medicinal maggots refers to a type of sterile intentional biological larval or biosurgical debridement that uses disinfected (sterile) maggots to clean wounds by dissolving the dead
    and infected tissue and by killing bacteria.9
    • “Eschar/Slough?
    o “Eschar? is described as thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered
    to the wound.
    o “Slough? is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy (at times).
    • “Exudate?
    o “Exudate? is any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury. It may contain serum, cellular debris, bacteria and leukocytes.
    o “Purulent exudate/drainage/discharge? is any product of inflammation that contains pus (e.g., leukocytes, bacteria, and liquefied necrotic debris).
    o “Serous drainage or exudate? is watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage.
    • “Friction/Shearing?
    o “Friction? is the mechanical force exerted on skin that is dragged across any surface.
    o “Shearing? is the interaction of both gravity and friction against the surface of the skin. Friction is always present when shear force is present.10 Shear occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood
    vessels causing tissue damage.
    • “Granulation Tissue?
    o “Granulation tissue? is the pink-red moist tissue that fills an open wound, when it starts to heal. It contains new blood vessels, collagen, fibroblasts, and inflammatory cells.
    • “Tunnel/Sinus Tract/Undermining?-Tunnel and sinus tract are often used interchangeably.
    o “Tunneling? is a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound.
    o A “sinus tract? is a cavity or channel underlying a wound that involves an area larger than the visible surface of the wound.
    o “Undermining? is the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface. Undermining often develops from shearing forces
    and is differentiated from tunneling by the larger extent of the wound edge involved in undermining and the absence of a channel or tract extending from the pressure ulcer under the adjacent intact skin.
  • OVERVIEW LEEDerGroup.com: KYDEX Pro Multi Podus boot with ambulation pad Prevent Mitigate Heel UlcersKYDEX PRO Multi Podus
    A pressure ulcer can occur wherever pressure has impaired circulation to the tissue. Critical steps in pressure ulcer prevention and healing include: identifying the individual resident at risk for developing pressure ulcers, identifying and evaluating the risk factors and changes in the resident’s condition, identifying and evaluating factors that can be removed or modified, implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. It is important to recognize and evaluate each resident’s risk factors and to identify and evaluate all areas at risk of constant pressure.
    A complete assessment is essential to an effective pressure ulcer prevention and treatment program. A comprehensive individual evaluation helps the facility to:
    • Identify the resident at risk of developing pressure ulcers, the level and nature of risk(s); and
    • Identify the presence of pressure ulcers.
    This information allows the facility to develop and implement a comprehensive care plan that reflects each resident’s identified needs. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate.
    The facility should have a system/procedure to assure: assessments are timely and appropriate; interventions are implemented, monitored, and revised as appropriate; and changes in condition are recognized, evaluated, reported to the practitioner, and addressed. The quality assessment and assurance committee may help the facility evaluate existing strategies to reduce the development and progression of pressure ulcers, monitor the incidence and prevalence of pressure ulcers within the facility, and ensure that facility policies and procedures are consistent with current standards of practice.
    Research into appropriate practices for the prevention, management and treatment of pressure ulcers, continues to evolve. As such, there are many recognized clinical resources regarding the prevention and management of pressure ulcers (including wound care, and complications such as infections and pain).
  • Some of these resources include:
    • The Clinical Practice Guidelines from the Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov (Guideline No. 15: Treatment of Pressure Ulcers and Guideline No.3: Pressure Ulcers in Adults: Prediction and
    Prevention)(AHRQ was previously known as the Agency for Health Care Policy and Research [AHCPR]);
    • The National Pressure Ulcer Advisory Panel (NPUAP) www.npuap.org;
    • The American Medical Directors Association (AMDA) www.amda.com (Clinical Practice Guidelines: Pressure Ulcers, 1996 and Pressure Ulcer Therapy Companion, 1999);
    • The Quality Improvement Organizations, Medicare Quality Improvement Community Initiatives site at www.medqic.org;
    • The Wound, Ostomy, and Continence Nurses Society (WOCN) www.wocn.org;
    • The American Geriatrics Society guideline “The Management of Persistent Pain in Older Persons?, www.healthinaging.org.
    NOTE: References to non-CMS sources or sites on the Internet are provided as a service and do not constitute or imply endorsement of these organizations or their programs by CMS or the U.S. Department of Health and Human Services. CMS is not responsible for the content of pages found at these sites. URL addresses were current as of the date of this publication.