Pressure Ulcers The New Investigative Protocols

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Pressure Ulcers The New Investigative Protocols

• Lynne Condon RNC, BS, RAC-C

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Objectives

• At the end of the session the attendee will be
• able to discuss
• The difference between avoidable and unavoidable
  pressure ulcers
• The changes that CMS has made to the Surveyors
  investigative protocols
• The importance of accurate assessment and follow
  through by nursing, in prevention and treatment
  of pressure ulcers

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History

• CMS Transmittal 4
• Released November 12, 2004
• New wording for direction to Surveyors
• New wording for F 309
• Non-pressure type ulcers
• Revision to F 314

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What is avoidable?

• Avoidable means that the resident developed a
  pressure ulcer and that the facility did not do
  one or more of the following

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The facility failed to

• Evaluate the residents clinical condition and
  risk factors
• Define and implement interventions that are
  consistent with the residents needs, goals and
  recognized standards of practice

• Monitor and evaluate the impact of the
  interventions
• Revise interventions as appropriate

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History

• Revised definitions and added clarifications for
  types of ulcers
• Including non-pressure
• Greater in depth definitions for
• Cleansing
• Colonization/Infections
• Debridement
• Types

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Investigative Protocols

• Surveyor Objectives
• Determine if ulcer(s) is avoidable or
  unavoidable and
• Determine adequacy of the interventions to
  prevent and treat pressure ulcers

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Investigative Protocols

• Sample is to include residents who have been
  identified as having ulcers
• Was ulcer caused by
• Pressure
• Non-pressure
• Review of MDS, Plan of Care and other risk
  assessments completed by the facility

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Investigative Protocols

• Observation
• Wound site and Treatment
• Preventive measures
• Positioning
• Pressure relief
• RD consult timely

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Investigative Protocols

• Does record accurately reflect current wound
  status?
• Description of site
• Stage
• Exudates
• Necrotic tissue eschar or slough
• Erythema or swelling around site

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Investigative Protocols

• Debridement
• Type or form if used
• If not used when site is clearly in need of
  debridement why was it not done?

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Investigative Protocols

• Treatment
• Does treatment meet current infection control and
  current standards of practice?
• Cleansing and protection for likely contamination
  by urine or fecal incontinence

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Investigative Protocols

• Interviews
• Licensed and unlicensed staff
• Record review
• Concurrent daily review notes
• Assessment MDS/RAI
• Accurate coding

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Investigative Protocols

• Record review cont.
• Was risk noted?
• When was risk first noted?
• Before or after the first skin breakdown?
• Did the plan of care reflect the noted risk?

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Investigative Protocols

• Record review cont.
• Did the facility monitor the site and note any
  signs of change/progression of the area?

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Quality The Critical Element of the Prevention
Factor

• Quality Measure Comparison Maryland and the
  Nation
• Long Term residents with pressure ulcers
• High risk 13 National 13
• Low risk 2 National 3
• Short Stay residents with pressure ulcers
• Maryland 19 National 19

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Quality The Critical Element of the Prevention
Factor

• Quality Indicators
• Average for Maryland homes 11.4
• Based on 100 to 120 bed facility
• High Risk 15.9 Low Risk 3.1

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Quality The Critical Element of the Prevention
Factor

• Review your QI data at least every quarter
• Determine thresholds for your facility
• Review and revise as needed

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Potential Tags

• 42 CFR 483.25 Quality of Care - F 309
• Each resident must receive and the facility must
  provide the necessary care and services to attain
  or maintain the highest practicable physical,
  mental and psychosocial well-being, in accordance
  with the comprehensive assessment and plan of
  care.

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Potential Tags

• 42 CFR 483.25 (c) F 314 Pressure sores
• Based on the comprehensive assessment of a
  resident he facility must ensure that
• The resident who enters the facility without
  pressure sores does not develop pressures unless
  the individuals clinical condition demonstrates
  that they were unavoidable and

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Potential Tags

• F 314 cont.
• Based on the comprehensive assessment of a
  resident he facility must ensure that (cont)
• The resident having pressure sores received the
  necessary treatment and services to promote
  healing, prevent infection and prevent new sores
  from developing.

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Potential Tags

• 42 CFR 483.10(b)(11)(i)(B)and (C) F157
  Notification of Changes
• Physician and family
• 42 CFR 483.20(b)(1) F 272 Comprehensive
  Assessments
• MDS/RAI

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Potential Tags

• 42 CFR 483.20(k)(1) F 279 Comprehensive Care
  Plans
• Surveyors looking for aggressive interventions
  started
• 42 CFR 483.20(k)(2)(iii) F 280
• Comprehensive Care Plan Revision
• If the current treatment or approaches are not
  working how timely did changes occur?

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Potential Tags

• 42 CFR 483.20(k)(3)(i), F 281 Services Provided
  Meet Professional Standard
• Has the facility implemented the current standard
  in treatment approach?
• If the surveyor observed the treatment did the
  nurse follow accepted standards of wound
  treatment and dressing
• 42 CFR 483.30(a), F 353 Sufficient Staff
• TAP
• Treatments delivered as ordered - frequency

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Potential Tags

• 42 CFR 483.40(a)(1), F 385 Physician Supervision
• How involved is the attending?
• Who changes orders for new treatment approaches?
• 42 CFR 483. 75(i)(2), F 501 Medical Director
• Does he/she step in when needed?
• How involved in facility QA?

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Helpful Web Sites

• www.ahrg.gov
• Agency for Healthcare Research and Quality
• www.npuap.org
• National Pressure Ulcer Advisory Panel
• www.amda.com
• American Medical Directors Association
• www.medqic.org
• Medical Quality Improvement Community
• www.wocn.org
• Wound Ostomy and Continence Nurses Society
• See Guidance on OASIS Skin and Wound
• www.healthinaging.org
• American Geriatrics Society Foundation for Health
  in Aging

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Points of Contact

• Linda Masterson RN, QA Technical Support Team
  Coordinator
• 410-402-8008
• lmasterson_at_dhmh.state.md.us
• William Vaughan RN, OHCQ Chief Nurse
• 410-402-8140
• wvaughan_at_dhmh.state.md.us
• Lynne Condon RNC
• 410-402-8102
• lcondon_at_dhmh.state.md.us
• Joseph Berman MD
• 410-402-8007
• jberman_at_dhmh.state.md.us