The way the nurse assessment coordinator (NAC) is tracking pressure ulcers may have changed, but that doesn’t mean the nursing team’s care process should.
As part of its annual October updates to the RAI User’s Manual, the Centers for Medicare & Medicaid Services (CMS) made some changes to how pressure ulcers are referred to and how they are coded.
First and foremost, the RAI manual has broadened the scope of its terminology, to include pressure injuries rather than just pressure ulcers.
CMS stated in the SNF QRP training held July 31 and August 1, 2018, that it will adhere to the following guidelines: Whereas the term pressure ulcer is used to describe an open wound, pressure injury usually refers to a wound that still has intact skin or is closed. In the RAI manual, Stage 1 injuries would be considered pressure injuries, while Stage 2, 3, and 4 injuries would be considered ulcers. Wounds that are unstageable due to slough or eschar are also considered ulcers, as they are more open. And wounds that are unstageable due to a removable dressing or device are referred to as pressure ulcers/injuries.
The RAI manual also removed several items from the MDS regarding pressure ulcers, including documenting the dimensions of an unhealed pressure ulcer (M0610), the most severe tissue type (M0700), worsening in pressure ulcer status (M0800), and healed pressure ulcers (M0900).
Rather than tracking worsening in pressure ulcers, now CMS is just requiring NACs to document whether there is a pressure ulcer present and whether it was present on admission.
“Essentially, if we code it as present on admission, that means the resident was admitted with this pressure ulcer and it has not worsened to a deeper anatomical stage under our care. If we code that it’s present but wasn’t present on admission, that means it was either acquired at the facility or it worsened under our care. CMS is using the coding at M0300 to replace the deleted items and to determine if we have a new or a worsened pressure ulcer during the course of a stay,” says Jessie McGill, RN, RAC-MT, and curriculum development specialist for AAPACN.
So what does that mean for staging and the wound treatment process?
Nothing. Just because the NAC is no longer tracking these items doesn’t mean the nursing staff shouldn’t be.
“Even though these items were removed from the MDS, it does not take away our clinical obligation to measure all wounds, to care for them, and to know the time frame in which they should be healing,” says McGill.
In other words, your nursing staff should still be evaluating and treating wounds with the same care and attention as always.
“The coding changes are not going to change our clinical practice whatsoever. We need to continue to monitor them and manage them as we always have done,” says Jeri Lundgren, RN, BSN, PHN, CWS, CWCN, CPT, founder/president of Senior Providers Resource, and wound specialist.
This begs the question, does your facility currently have an effective clinical process for wound evaluation and treatment? It never hurts to review the processes and procedures.
Here are some of the important components of evaluating, assessing, and monitoring pressure ulcers and injuries, according to Lundgren:
1. Assess for the resident’s risk of getting pressure injuries: It’s important to assess for risk on admission, weekly for the first four weeks after admission, monthly (which is a regulation change—it used to be a quarterly requirement), and then whenever there’s a change of condition.
2. Conduct regular full-body skin assessments: It’s also good practice for a licensed staff member to do a head-to-toe skin assessment at least once a week. Additionally, nursing assistants who provide daily care should consistently monitor the skin for risk of breakdown.
3. Measure and stage the wound properly: The wound should be measured for length, width, and depth, and the wound bed tissue needs to be properly described and staged. The stages are thoroughly described in item M0300 of the RAI User’s Manual:
STAGE 1 PRESSURE INJURY: 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: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the injury may appear with persistent red, blue, or purple hues.
STAGE 2 PRESSURE ULCER: Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.
STAGE 3 PRESSURE ULCER: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling (see definition of undermining and tunneling on page M-17).
STAGE 4 PRESSURE ULCER: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Quite a bit of training is involved in properly measuring length, width, and depth and properly staging an injury. So it’s important that whoever is conducting the wound assessment have proper training.
4. Don’t just check the boxes—consider all individual risk factors:
“When you’re assessing for risk of skin breakdown, it’s very important that you use that risk assessment as a living, breathing tool. Don’t just use it for paper compliance. You need to look at what the resident triggered individually for those risk factors. If you’re using a validated scoring tool, those individual risk factors need to be broken down,” says Lundgren. “The overall scoring tool will tell you if the risk is high, low, medium, whatever. But it’s more important to understand what individual subset puts the resident at risk, and then from there develop a plan of care that is based on those risk factors. You’re trying to put interventions in place to modify, stabilize, or eliminate those individual risk factors for that resident.”
One of the biggest risk factors for developing pressure ulcers or injuries is, of course, immobility, but other risk factors also need to be considered, such as the resident’s diet. Some examples of individual interventions based on risk factors could include:
· The type of support surface for the bed and wheelchair
· The turning program
· Propping the resident’s heels up off the bed
· Improving how incontinence is managed
5. Make sure all nursing staff members are proficient in wound assessment: It’s all too easy to become reliant on your facility’s wound specialist to assess and treat pressure ulcers and injuries. But the wound nurse can’t be available 24/7. If a new resident is admitted with a wound, or if a wound develops over the weekend, what’s your backup plan? That’s why it’s important that all the nurses in the facility be competent in assessing and treating a wound. The wound nurse can then reevaluate upon returning to the facility to ensure the assessment and treatment are appropriate—without there having been a delay in providing the resident with proper wound care.
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