Skin/Pressure Ulcers F309/F314 Implementation Date 11/12/04

Skin/Pressure UlcersF309/F314

Implementation Date

11/12/04

F309 – 483.25 Quality of Care

• 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.

No change

F309 – Intent

The facility must ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident’s right to refuse treatment, and within the limits of recognized pathology and the normal aging process.

No change

Definitions

• Important to differentiate between a pressure ulcer and a skin ulcer/wound.

Arterial Ulcers• Arterial Ulcer – non-pressure related

disruption or blockage of the arterial blood flow.

• Underlining cause may be:– Moderate to severe peripheral vascular disease.– Generalized arteriosclerosis.– Inflammatory or autoimmune disorder.– Significant vascular disease elsewhere.

Arterial Ulcer• Characteristics:

– Painful

– Distal portion of the lower extremity

– May be over ankle or bony areas of the foot

– Wound bed is dry and pale with minimal or no exudate.

– Diminished/absent pedal pulse

– Cool to touch

– Pain/blanching on elevation

– Hair loss

– Toenail thickening

Diabetic Neuropathic Ulcer

• Requires the resident to be diagnosed with diabetes mellitus and have peripheral neuropathy.

• Characteristically occurs on the foot.

Venous Insufficiency Ulcer (Stasis Ulcer)

• Open lesion of the skin and subcutaneous tissue of the lower leg usually occurring in the pre-tibial area of the lower leg or above the medial ankle.

• Most common vascular ulceration.

• Difficult to heal.

• Venous hypertension is a causative factor.

F314 – 483.25(c) Part 1Pressure Sores

• 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.

No change

F314 Intent

• Part 1: Residents do not develop pressure ulcers unless they are unavoidable.

Unavoidable

• Unavoidable:

– Assessed

– Care planned

– Care plan implemented

– Evaluation of outcomes

– Care plan revised

Unavoidable

Not all pressure ulcers are avoidable

– Multi system organ failure or end of life condition.

– Refusing care and treatment.

F314 – 483.25(c) Part 2Pressure Sores

A resident having pressure sores receives the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.

F314 – Intent

Part 2: The facility provides care and services to:

– Promote healing of current ulcers.

– Promote prevention.

– Prevent infection.

– Prevent development of additional pressure ulcers.

Definitions

• Pressure ulcer – lesion caused by unrelieved pressure that results in damage to the underlying tissue.

• Friction/shear – contributing factors.

Assessment

• Assessment (Initial and ongoing)– Identify risk factors (the at risk resident

can develop a pressure ulcer within 2 to 6 hours of the onset of pressure.)• Which can be removed/modified?

– Identify pre-existing signs (purple or very dark area surrounded by profound redness, edema, induration, bogginess, coolness, increased warmth.)

Assessment - Risk Factors

• Impaired/decreased mobility and/or functional status.• Co morbid conditions• Drugs (steroids effect healing)• Impaired blood flow• Resident refusal• Cognitive impairment• Exposure to urinary/fecal incontinence• Under nutrition, malnutrition, hydration deficits• A healed ulcer (Stage III and IV)

Assessment

– Evaluate current skin condition.– Evaluate underlying medical conditions.– Consider intrinsic factors do to aging.

• Decreased subcutaneous tissue

– Evaluate the nature of the pressure to which the resident maybe subjected.

• Pressure intensity• Pressure duration• Tissue tolerance

AssessmentFrequency Suggestion

• Significant number of pressure ulcers develop within the first 4 weeks of admission.– Use a standardize risk assessment on admission– Repeat weekly for the first 4 weeks– Repeat quarterly – Repeat whenever there is a change

Interventions

• Comprehensive assessment provides the basis for defining approaches.

• Effective prevention and treatment are based upon consistently providing routine and individualized interventions.

• Care plan with relevant goals and approaches to stabilize/improve co-morbidities.

Interventions

• Resident choice – discuss choices with resident and/or family.

• Advanced Directive

– Does not prevent the facility from giving supportive, pertinent care.

Interventions

• Basic/Routine care:– Redistribute pressure (repositioning, protecting

heels.)– Minimize exposure to moisture, keep skin clean.– Provide appropriate pressure redistributing ,

support surfaces– Provide non-irritating surfaces– Maintain or improve nutrition and hydration

status, where feasible

Interventions

• Repositioning – Resident may need supportive devices to

facilitate position changes.– At least every 2 hours or more frequently

– dependent on tissue tolerance.– Elevating the chair back/head on bed

greater then 30 degrees is comparable to sitting.

Interventions

• Teach a resident to shift weight every 15 minutes while sitting in chair.

• Wheelchairs with sling seats are not optimal for prolonged sitting.

• Momentary pressure relief does not allow sufficient capillary refill and tissue perfusion.

Interventions

• Support Surfaces and Pressure Redistribution– Distribute load over a surface or contact area.

• Pressure reduction (reduction of interface pressure, not necessarily below capillary closure pressure)

• Pressure relief (reduction of interface pressure below capillary closure pressure)

– Effectiveness needs to be evaluated on an ongoing basis.

Interventions

• Static pressure redistribution devices (solid foam, convoluted foam, gel mattress)– Used for resident at risk for pressure ulcer

development or delayed healing.

Does not eliminate the necessity for periodic repositioning

Interventions

• Dynamic pressure reduction surfaces– Used when resident cannot assume a variety of

positions without bearing weight on a pressure ulcer.

– Used when resident completely compresses a static device that has retained its original integrity.

– Pressure ulcer is not healing and it is determined pressure may be contributing to the delay in healing.

Interventions

• Friction – mechanical force exerted on the skin that is dragged across any surface.

• Shearing – interaction of both gravity and friction against the surface of the skin.

Interventions

• Weight reflects a balance between intake and utilization of energy.

• Consider:– Severity of the nutritional compromise

– Rate of weight loss or appetite decline

– Probable cause

– Prognosis

– Projected clinical course

– Resident wishes and goals

Interventions

• Resident who is nutritionally compromised and has a pressure ulcer:– Protein intake 1.2 to 1.5 gm/kg body weight– Simple multivitamin– Clinical observation

• Some laboratory tests may help – no laboratory test is specific or sensitive enough to warrant serial/repeated testing. (A low albumin level combined with the facility’s lack of supplementation is not sufficient to cite a pressure ulcer deficiency.)

Interventions

• Debridement• Removal of devitalized/necrotic tissue and foreign

matter from a wound – improve/facilitate healing.– Autolytic debridement

– Enzymatic (chemical) debridement

– Mechanical debridement

– Sharp or surgical debridement

– Maggot debridement therapy

Interventions

• Pain Control• Pain:

– Integral component of pressure ulcer prevention and management.

– Eliminate the cause– Provide analgesia

• Assessing pain in the cognitively impaired. • Individual perception.

Infection

Current literature reports that all Stage II, III,

and IV are colonized with bacteria but may

not be infected.

Infection

• Colonized – presence of bacteria without the signs and symptoms of an infection.

• Infected – presence of bacteria in sufficient quantities to overwhelm the defenses of viable tissue and produce the signs and symptoms of infection.

Infection• Classified as infected:

– If signs and symptoms of infection are presentand/or

– Wound culture contains 100,000 or greater micro-organisms per gram of tissue.

• Findings such as elevated white blood cell count, bacteremia, sepsis or fever may signal pressure ulcer infection or co-existing infection from a difference source.

Evaluating• At least daily – evaluate and document.

– Evaluate the ulcer and status of area surrounding the ulcer

– Evaluate the dressing– Evaluate for complications and pain.

• At least weekly evaluate and document:– Location and staging– Size– Exudate– Pain– Wound bed– Description of wound edges and surrounding tissue

Evaluating

• Assessing ulcer:– Differentiate the type of ulcer (pressure or non-

pressure)– Stage– Describe/Monitor characteristics – Monitor progress– Watch for infection– Assess, treat and monitor pain– Monitor dressing and treatments

Evaluating

• Eschar – thick, leathery, (black or brown color) dead/devitalized tissue. May be loose or firmly adhered to the wound.

• Slough – Necrotic tissue in the process of separating from the viable portions of the body. Soft, moist, light in color.

Evaluating

• Exudate - any fluid that has been forced our of the tissue because of inflammation or injury.– Purulent exudate/drainage/discharge – Product

of inflammation – contains pus.– Serous drainage or exudate – watery, clear,

yellowish/tan /pink in color that separates from the blood and presents as drainage.

Evaluating

• Granulation Tissue - Pink-red moist tissue that fills al open wound when it starts to heal. Contains new blood vessels, collagen, fibroblast, and inflammatory cells.

Evaluating

• Undermining – destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at the base than at the skin surface.

Evaluating

• Tunneling – passageway of tissue destruction under the skin surface that has an opening at the skin level.

• Sinus Tract – Cavity or channel underlying a wound that involves an area larger than visible surface of the wound.

Evaluating• Staging:

– Stage I– Stage II– Stage III– Stage IV

• If eschar and necrotic tissue covering and preventing adequate staging code as Stage IV.

Evaluating

• Clean pressure ulcer with adequate blood supply and innervation should show evidence of stabilization or some healing within 2-4 weeks.

• If no evidence of progress toward healing within 2-4 weeks – reassess.

PRESSUER ULCER INVESTIGATIVE PROTOCOL

F314 – Investigative Protocol Pressure Ulcers

• Objectives:– To determine if the identified pressure(s) ulcer

is avoidable or unavoidable.– To determine the adequacy of the facility’s

intervention and efforts to prevent and treat pressure ulcers.

F314 Investigative Protocol

• Use– Sampled resident having, or at risk of

developing a pressure ulcer.

• If not a pressure ulcer – do not proceed with this protocol.


• Procedures:– Briefly review the assessment, care plan and

orders.

• Observation

• Interview

• Record review


1. Observation:

– Do staff consistently implement the care plan over time and across various shifts?

• Note/follow-up on deviations from the care plan.

• Note/follow-up on potential negative outcomes.


• Look for erythematic or color changes on areas such as the sacrum, buttocks, trochanters, posterior thigh, popliteal area, heels when moved off the area:– If noted – return ½ to ¾ hours later

determine if characteristics persist.

F314 Investigative ProtocolPotential Negative Outcomes

– If changes persist and exhibit tenderness, hardness or alteration in temperature from surrounding skin – interview staff:

• Positioning schedule.

• Policy and procedure for addressing a Stage I pressure ulcer.

F314 Investigative Protocol Potential Negative Outcome

• Look for previously unidentified open areas.• Look at resident positioning. Is the resident

positioned to avoid pressure on an existing pressure ulcer?

• Does the facility prevent shearing or friction during transfers, elevation and repositioning?

• Are pressure-redistribution devices in place and working?


• Observe existing ulcer and wound care.• Characteristics of the wound and surrounding tissue.

• Type of debridement.

• Treatment and infection control practices reflect current standards of practice.

• Steps taken to clean/protect from contamination by urine or fecal incontinence.

• Does the clinical record reflect the current status of the ulcer?


• Unable to observe due to dressing protocol:– Inspect surrounding tissues– May request the dressing be removed if other

information suggests a possible treatment/assessment problem


• Resident expresses pain related to the ulcer or treatment:– Was the resident assessed for pain?– Were preemptive measures taken?– Were the preemptive measures effective?


2. Interviews• Resident/family/responsible party:

– Were they involved in care plan, choices, goals? Do interventions reflect their preferences?

– Are they aware of the approaches being used?– Is there presence of pain? How is it managed?– If treatment was refused were they counseled on

alternatives, consequences?– Are they aware of the history of the pressure ulcer? The

cause?


• Staff interviews – various shifts:– Does the staff have knowledge of prevention

and treatment?– Do the nursing assistants know what, when, and

to whom to report changes in skin condition?– Who monitors for the implementation of the

care plan?– Who monitors treatment, frequency of review

and evaluation of the ulcer?


3. Record Review:

– Documentation should include:• Assessment of overall condition• Risk factors• Presence of existing pressure ulcer

•F314 Investigative Protocol

• If the resident was admitted or developed an ulcer within 1 to 2 days of admission:– Review admission documentation (site,

characteristics, tissue damage due to immobility or prior illness, skin condition on day of admission, nutritional history, previous pressure ulcer.)


• Resident who subsequently developed or has an existing pressure ulcer:– Review documentation (wound site,

characteristics , progress and complications.)– If no signs of healing within 2 to 4 weeks was

the wound/treatment reassessed?


• Care plan:– Is it individualized?

– Does it address prevention, care, and treatment?

– Are there specific interventions, measurable goals, time frames.


• Revision of care plan:

– Is staff monitoring resident’s response to interventions?

– Is the care plan revised based on resident’s responses, outcomes and needs?


If interventions/care provided appears not to be consistent with recognized standards of practice interview one or more health care practitioners/ professionals (physician, charge nurse, DON.)

How was it determined that the chosen interventions were appropriate?


– Are there risks identified with this treatment for which there are no interventions?

– Do changes in condition justify additional or different interventions?

– How is the effectiveness of the current interventions validated?

Criteria for Compliance

• Resident with acquired pressure sore:– Assessed (risk factors identified and skin condition)

– Developed and implemented a plan of care based on the resident needs

– Monitored and evaluated response to interventions

– Revised approaches as appropriate

• If not, the pressure ulcer was avoidable. Cite at F314.

Criteria for Compliance

• Resident admitted with pressure ulcer, non-healing pressure ulcer, at risk of developing subsequent pressure ulcers:– Assessment (risk factors and skin condition)– Developed and implemented a plan of care based on

resident needs– Address potential infection– Monitor/evaluate response– Revise approaches as appropriate

• If not cite at F314.

F314 Non-compliance

• May include one or more of the following:– Failed to accurately or consistently assess.– Failed to identify and address risks for

developing pressure ulcers.– Failed to implement preventative interventions

in accord with the resident’s needs and current standards of practice.

F314 Non-compliance

• Failed to provide clinical justification for the unavoidable development or non-healing/delayed healing or deterioration of a pressure ulcer.

• Failed to provide appropriate interventions, care and treatment to an existing pressure ulcer to minimize infection and promote healing.

F314 Non-compliance

• Failed to implement interventions for existing wounds.

• Failed to notify physician of residents condition or changes in resident’s wound care.

• Failed to adequately implement pertinent infection management practices.

• Failed to identify or know how to apply relevant policies and procedures for prevention and treatment.

Potential tags for AdditionalInvestigation

• F157 - Notification of changes

• F272 - Comprehensive assessment

• F279 - Comprehensive Care Plans

• F280 – Comprehensive Care Plans

• F281 – Services provided in accordance with accepted professional standards

• F309 – Quality of care

Potential tags for AdditionalInvestigation

• F353 - Sufficient Staff

• F385 - Physician Supervision

• F501- Medical Director

Severity Determination

• Key elements for severity determination:– 1. Presence of harm/negative outcomes or

potential for negative outcomes because of lack of appropriate treatment and care.

– 2. Degree of harm (actual or potential) related to the non-compliance.

– 3. The immediacy of correction required.

Severity

• Level 4 – Immediate Jeopardy to health/safety.– Facility non-compliance has caused or is likely

to cause serious injury, harm, impairment, death.

– Requires immediate correction

Examples – Level 4

• Development of avoidable Stage 4.

• Admitted with Stage 4 – no healing or deterioration.

• Stage 3 or 4 with associated soft tissue or systemic infection.

• Extensive failure in multiple areas of pressure ulcer care.

Severity

• Level 3 – Actual harm.– Clinical compromise.– Decline.– Impact resident’s ability to maintain and/or

reach highest practicable well-being.



• Development of recurrent or multiple avoidable Stage 2.

• Failure to implement the comprehensive care plan for a resident who has a pressure ulcer.

Severity

• Level 2– Minimal discomfort.– Potential to compromise ability for maintain or

reach highest practicable level of well being.– Potential for greater harm.


• Development of single avoidable Stage 2 that is receiving appropriate treatment.


• Failure to implement an element of the care plan – no evidence of decline.

• Failure to recognize or address the potential for developing a pressure ulcer.

Severity – Level 1

• No actual harm with potential for minimal harm.– Does not apply to this regulatory requirement.

F314 - Overview

• Research into appropriate practices for pressure ulcer prevention and healing.– The Clinical Practice Guidelines

• www.ahrq.gov- Guideline #15

– The National Pressure ulcer Advisory Panel (NPUAP)

• www.npuap.org

http://www.npuap.org/

F314 - Overview

– The American Medical Directors Association (AMDA) • www.amda.com

– The Quality Improvement Organization• 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

http://www.amda.com/

http://www.medqic.org/

http://www.wocn.org/

QUESTIONS

Documents

Skin/Pressure Ulcers F309/F314 Implementation Date 11/12/04