Section F-314 through a Long-term Care Surveyor’s Eyes

    Much has been written about the revision to F-314 Instruction to Surveyors, the guidance document that addresses pressure ulcer management in long-term care.^1,2 Understanding exactly how a surveyor might view the pressure ulcer care provided in a facility in accordance with the Centers for Medicare and Medicaid Services (CMS) regulations may be helpful to long-term care providers. The following is an actual example of a survey conducted in a long-term care facility.

    For clarity, the regulatory information below precedes the summary of deficiencies documented by the surveyor.

F-314 483.25(c) Pressure Ulcers

    F-314. Based on the comprehensive assessment of a resident, the facility must ensure that 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 a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.

    Deficiencies. Based on observation, one-on-one interviews with residents and staff, and review of residents’ medical records and the facility’s policy/procedure manuals, the facility failed to provide interventions consistent with current standards of practice and failed to render the necessary treatment and services to promote healing in six of the 24 residents sampled.

    Evidence. Resident X was admitted on March 1, 2001 with a pressure ulcer on the coccyx and several other medical diagnoses. The review period for the treatment of this pressure ulcer was 6 months (January 2005 through July 2005). At the beginning of the review period, the ulcer was documented on the facility’s nursing wound and skin form as a Stage III, 2 x 2 and 0.5 deep. Three months later, the wound and skin form recorded the wound as a Stage IV, 3 x 2 without any documentation of depth. Neither of the notes clearly indicated the unit of measurement (centimeters or inches) used. A review of the facility’s policies and procedures also found no direction as to the unit of wound measurement required within the facility. However, the staging information and documented wound measurements demonstrate that the pressure ulcer deteriorated to a Stage IV and that no healing had occurred in 6 months.

    In June, an order for daily wet-to-dry dressing for 30 days appeared on the physician order sheet, even though no evidence of necrotic tissue or slough was documented on the nursing wound and skin form. During the survey in July, the surveyor observed the treatment nurse conducting the daily wet-to-dry dressing change on Resident X. The wound bed contained bone and viable red tissue with no evidence of slough or necrotic tissue. The treatment nurse reported that she would continue the daily wet-to-dry dressings as ordered. In the absence of slough or necrotic tissue, daily wet-to-dry dressings are contraindicated.

    Subsequently, the charge RN was interviewed regarding the physician’s order for wet-to-dry dressings. She stated that the order was verbally obtained from a licensed visiting nurse (LVN) Wound Care Consultant to the facility and was written into the physician orders. However, the order was not signed by the physician and no documentation of how the order was obtained (verbal or telephone) was recorded. A telephone call was placed to the LVN Wound Care Consultant who stated she had only made a treatment recommendation and that it was up to the charge RN to forward her recommendation to the physician and obtain a proper order. An additional one-on-one interview with the Wound Care Consultant revealed that she was an employee of a support surface company and that it was her company’s policy only to make treatment recommendations and not to generate any documentation in the medical record related to her treatment recommendation. Her name badge revealed only her name and not her professional credentials or the name of her company. The only substantiation of her nursing credentials was her own verbal confirmation that she was a licensed registered nurse.

    The facility also had a policy to photograph newly admitted residents who displayed any skin problems or pressure ulcers. Photographic documentation of wounds and skin also should have been conducted before discharging residents. No photographs of wounds were found in any of the medical records reviewed. An interview with the Director of Nursing revealed that no photographs were being taken on either newly admitted or ready-for-discharge residents.

    A review of the personnel record of the treatment nurse failed to produce evidence of any formal training related to basic wound care, wound care assessment, or treatment of pressure ulcers. During a one-on-one interview with the surveyor, the treatment nurse confirmed that she had not undergone any recent training in pressure ulcer care nor did she have knowledge of how education had been more intensely integrated into the Medicare survey process.

Lessons Learned

    Surveyors make many determinations during their visit to a facility. Regardless of the source or sources used to make these determinations, each one depends on a variety of factors that must be based on best wound care practice and adherence to CMS regulations and evident through well documented, explicitly implemented, consistent wound care. A facility’s internal policies and procedures must be in harmony with best practice and CMS regulatory requirements. As demonstrated through this real-life survey, the importance of having a standardized system of education regarding Medicare policy and modern wound treatment, assessment, and prevention — as well as accurate documentation — cannot be overemphasized. Research has proven that healing a wound is more expensive than preventing one. The same could be said for long-term care facilities: Non-compliance is more expensive than compliance.

1. Lyder C, van Rijswijk L. Pressure ulcer prevention and care: preventing and managing pressure ulcers in long-term care: an overview of the revised federal regulation. Ostomy Wound Manage. 2005;51(4 suppl):2–6.

2. Turnbull GB. Nursing home surveys: it’s just fundamentals. Ostomy Wound Manage. 2004;50(12):28–29.