Revised Guidance to Surveyors for Pressure Ulcers Effective End of 2004

    The new year begins with long-term care providers clambering to understand the long-awaited revision to the Guidance for Surveyors and Investigative Protocol: Pressure Ulcers for Tag F-314 that became effective on November 12, 2004.

The 40-page document contains detailed definitions of specific terms used in the manual instructions, including “avoidable and unavoidable pressure ulcers,” an overview of pressure ulcer prevention, assessment, treatment interventions, and ongoing monitoring of the patient’s wound and skin. It also contains specific instructions on how to document healing pressure ulcers on the Minimum Data Set (MDS) which still requires “back staging” until the MDS is revised sometime in the future.

Back to Basics

    The revised Guidance appears to be more evidence-based than the prior version and reflects current clinical best practice. Therefore, the onus is on long-term care providers to ensure all staff levels are capable of assessing and providing appropriate care from the day of admission until discharge. “A facility should be able to show that its treatment protocols are based on current standards of practice and are in accord with the facility’s policies and procedures as developed with the medical director’s review and approval.”¹

    For example, a surveyor’s interview of a nursing assistant (NA) should demonstrate that the NA knows what, when, and to whom changes in a resident’s skin condition should be reported. It is expected that residents’ family members or responsible parties are involved in and aware of the resident’s care plan, goals, and treatments. If a resident refuses or resists interventions to reduce risk or treat an existing pressure ulcer, documentation in the care plan should reflect staff efforts to seek alternatives to address the needs identified in the assessment.

The Importance of the Admission Assessment

    Another interesting point clarified in the document addresses the old battle between the hospital and nursing home that “the pressure ulcer developed during the ambulance ride between the hospital and the nursing home.” The nursing home claims the pressure ulcer developed in the hospital and the hospital claims it developed in the nursing home. Who is ultimately responsible? The Guidance document emphasizes the critical importance of the facility’s admission assessment. A comprehensive and careful assessment may identify pre-existing signs such as a “purple or very dark area surrounded by profound redness, edema or induration”¹ that would suggest that deep tissue damage already has occurred and additional deep tissue loss should be anticipated. This deep tissue damage could lead to the appearance of an unavoidable Stage III or Stage IV pressure ulcer within days of admission or progression of a Stage I pressure ulcer to an ulcer with exudate or eschar. In these situations, the deep tissue damage already had occurred, either by prolonged immobility during hospitalization or surgery, a long ambulance ride, or while waiting to be found after a fall or stroke. This assessment also will help identify terminally ill residents or residents with multiple-system failure or those who refuse care and treatment. If a patient refuses treatment, documentation should demonstrate that an evaluation of the basis of the refusal was conducted and potential alternatives were sought.

    As a caveat, however, the document clearly states that if a determination is made that a resident is at high risk of developing a pressure ulcer, this does not in itself guarantee that the development of a pressure ulcer will be considered unavoidable.

Pressure Ulcer Treatment

    The Guidance document and Investigative Protocol make it clear that no single dressing promotes healing of all pressure ulcers within a specific stage. Rather, dressing selection should be based on the benefits the dressing could provide 1) to the specific characteristics of the wound wherever it may be in the healing process, 2) to the treatment goals, and 3) if used according to the manufacturer recommendations. Wound exudate should be managed with a dressing with an absorptive capacity and the co-existing ability to maintain moisture balance in the wound. The recommended use for wet-to-dry gauze is limited to certain circumstances but a caveat for repeated use alludes to the fact that gauze may re-injure healthy granulation tissue upon removal and cause bleeding and pain.

Overall Objective

    The overall objectives of the revised Guidance document and Investigative Protocol are twofold: 1) to determine if an identified pressure ulcer is avoidable or unavoidable and 2) to determine the adequacy of the facility’s interventions and efforts to prevent and treat pressure ulcers. As simple as it sounds, this is not a simple undertaking. It will require all long-term care facilities to re-examine their existing pressure ulcer prevention and treatment programs to ensure that they reflect current best clinical practice. Next, facilities must educate staff on the program, their accountability and responsibilities, and appropriate documentation. Hopefully, the implementation of these new standards will help elevate the level of pressure ulcer care and reduce the incidence of developing new pressure ulcers in the long-term care setting.

1. CMS Manual System. Pub. 100-07 State Operations, Provider Certification, Transmittal 4. Guidance to Surveyors for Long Term Care Facilities. November 12, 2004. Available at: www.cms.hhs.gov/manuals/pm_trans/R4SOM.pdf. Accessed November 16, 2004.