Focus On…Pressure Relief & Wound Care

Implementing the new CMS guidelines for wound care

Areas for potential citations are explained by Jeffrey M. Levine, MD, AGSF, CMD; Marilyn Pete rson, RNC, MSN; and Fay Savino, RN, BSN, MA

We suggest that facilities first become familiar with the guidelines, and then completely review their internal systems for wound care, including the policy and pro cedure (P&P) manual. Good wound care is dependent on many aspects of the care process, and this is reflected in the new CMS guidelines, which include emphasis on resident assessment and care planning. New citations are add ed for lack of physician and medical director involvement with wound care, as described below. Since emphasis i s added on physician notification and the correct use of products, internal review should include the responsiv eness and effectiveness of physician services. Remember that wound care is interdisciplinary and includes not o nly medicine and nursing but also nutrition, rehabilitative services, and social work.

Risk Assessment
Risk assessment is an important component of any wound care program. Risk assessm ent for pressure ulcers should be performed on every resident upon admission along with a complete body check f or preexisting ulcers. The Braden Scale is a popular measure, although others are available. ³ Whate ver scale is employed, it should be administered upon admission, then weekly for one month, and then quarterly. Because the risk for pressure ulcers rises with changes in medical status, the risk-assessment scale should be repeated whenever a medical illness or change in status occurs, including such events as stroke, delirium, fra cture, new onset of diabetes mellitus, or any infection, such as UTI or pneumonia.

Accuracy is critical when performing a risk assessment. When the medical record is reviewed by a surveyor, each subscale should corr espond accurately to the patient’s condition at that time. Therefore, in-services on use of the assessment scal e are important components of the wound care program. Conduct in-services for all nurse managers and other indi viduals delegated the task of completing the scale. Quality assurance (QA) review is recommended to ensure accu rate determination of the subscales.

The system for documentation of risk requires facility-wide review, beginning with review and revision of the P&P manual and the charting system’s organization. An important cons ideration is the construction of the medical record for ease of review. Risk-assessment results should be congr egated in a separate section, thereby allowing for ease of retrospective review of documentation timeliness and accuracy by QA and survey personnel. An alternative method is to place the risk-assessment documentation withi n the interdisciplinary notes in a clearly marked entry.

The Prevention Plan
The facility should maintain an armamentarium of prevention modalities for residents deemed at risk for pre ssure ulcers. The most basic is the turning and positioning schedule, which is supplemented by pressure-relief solutions such as heel pads, seating cushions, mattress overlays, and specialty mattresses. ⁴ The ne w CMS guidelines contain an introduction to support surfaces, including static and dynamic pressure-reduction d evices. Static pressure redistribution devices simply are cushioned surfaces, while dynamic devices have intrin sic movement. An example of a dynamic pressure-reduction surface is the alternating pressure air mattress.
< BR>The basic turning and positioning schedule is every two hours, but some patients at risk require even greate r frequency because of compromised tissue tolerance. ⁵ Whether or not the facility’s P&P manual requ ires documentation with turning and positioning flow sheets, an auditing system must exist to enforce facility- wide compliance with turning once a resident is deemed at risk.

Several resident characteristics affect the ease of enforcing a turning schedule. Residents with feeding tubes or those on ventilators, for example, ma y not be turned in the same manner as those not attached to life support. Residents with contractures can be tu rned but may need specially positioned pillows or cushions to maintain proper pressure relief. Thus, an individ ualized care plan can provide a guide to pressure-relief management.

Mobilization strategies are always a component of pressure-sore prevention. These include physical therapy and occupational therapy involvement fo r body strength improvement, balance training, and adaptive equipment. These therapists often are able to provi de suggestions for proper seat cushions and positioning devices. A speech therapy consult is helpful when deter mining ability to swallow and the need for special diets and therapies.

An individualized care plan shou ld be constructed for each resident deemed at risk by the risk-assessment scale. This care plan should take int o consideration factors that interfere with pressure relief, such as the life-support modalities mentioned abov e, and should address pressure-relief devices currently in use. Incontinence management for relief of moisture and fecal contamination is a must in any skin-management plan. In addition, the care plan should address nutrit ion and refer to the appropriate section of the medical record that covers this. It is important for QA efforts to review the appropriateness as well as the timeliness of care plan interventions.

Ulcer Documentation and Treatm ent
Pressure sore documentation should begin upon admission if a pressure ulcer is present, prefe rably within 24 hours of the resident’s entering the facility. Once an ulcer is detected, whether the resident is admitted with one or it is facility-acquired, a physician should perform a timely examination. Residents wit h pressure sores usually require review of their medical problems and a nutrition consultation, and the new CMS guidelines contain revised pressure ulcer investigative protocols that specifically target physician notificat ion for changes in the resident’s condition or wound(s).

A pressure sore’s location can sometimes assist in pinpointing system problems that require intervention. For example, bilateral ischial ulcers frequently res ult from improper seating. Ulcers on the perineum that are surrounded by dermatitis may indicate fungal infecti on or inadequate continence care.

The first step in proper wound documentation is determining the correc t diagnosis. The new CMS guidelines specifically mention arterial/ischemic ulcers, venous insufficiency ulcers (formerly known as the stasis ulcer), and diabetic neuropathic ulcers. It is critical that the diagnosis be mad e as early as possible and that the diagnostic process be carried forth with all disciplines, not only for surv eyors and QA, but also for risk-management purposes. We therefore advise obtaining a physician consultation for assistance with diagnosing lower extremity ulcers and for clarification of ulcer type. Noninvasive vascular st udies can be of crucial assistance in documenting ulcers associated with peripheral vascular disease. Consisten cy of documentation is important: If an ulcer is designated a pressure ulcer in one place and an arterial/ische mic ulcer elsewhere, this may spell trouble when a surveyor investigates the resident.

For documentation purposes, simply stating the stage of the ulcer is insufficient. Description of the wound should be accompanie d by measurements of length, width, and depth, as well as notation of odor and presence of drainage. The new CM S guidelines contain specific definitions of tunneling, sinus tract, undermining, eschar, slough, exudate, and granulation tissue. These definitions, as well as the staging system, need to be understood by staff entering w ound documentation into the medical record. The best documentation contains not only stage and measurements, bu t also a narrative description of the wound, current treatment, and response to treatment. It is helpful to doc ument the treatment in progress and the rationale for that treatment (i.e., absorbs drainage, treats infection, protects surrounding skin, debrides eschar, etc.).

Documentation in the medical record should be organi zed to facilitate QA and/or surveyor review. As with the risk-assessment results discussed above, we recommend congregating the wound care flow sheets and documentation in a separate section. This, however, does not elimin ate the need to discuss wound prevention and care in the narrative nursing notes.

The presence of pain i s an important consideration when caring for wounds, and this is indeed reflected in the new CMS guidelines. Pa in can result from the wound itself or can be a consequence of prevention measures or treatment. ⁶ T urning and positioning a frail resident with arthritis and contractures can be painful for him/her. Dressing ch anges can induce pain, with positioning of the resident and removal of adhesives. Pain should be assessed and d escribed in the wound documentation note and addressed in the care plan and physician record.

Photograph s can provide excellent supplementary documentation of wounds but should never take the place of written descri ptions. Each facility must decide whether photographs should be part of its wound care documentation program. T his decision should not be taken lightly, as the incorporation of photographs into wound care documentation is a decision that will require new P&Ps, staff training, expenses for a camera and printing, and incorporation of the photographs into the charting system.

Physician Involvement and Wound Care Formula ry
The previous CMS guidelines to surveyors were silent on the issue of physician involvement in wound care. A surveyor now is advised to investigate related F-tags for associated citations such as not notify ing the physician of changes (F157), not using correct products (F281), not providing adequate physician superv ision for wound care (F385), and not involving the medical director in the wound care program (F501) (table 2). Facilities therefore have ample incentive to get their medical directors on board with reviewing and implement ing a stronger wound care program, and educating their physicians about wound assessment and the correct use of products.

The medical director is delegated the task of supervising the primary care physicians in thei r wound assessment and documentation. All too often, primary care physicians rely on the nursing staff to perfo rm wound assessments and decide on treatment modalities. The physician assessment should reflect the presence a nd location of the wound, as well as treatment and response to care. The medical documentation also should disc uss conditions such as diabetes mellitus, peripheral vascular disease, weight loss, and stroke, which may adver sely affect response to treatment.

Primary care physicians should be familiar with advanced wound care m odalities and their proper use. The new CMS guidelines state, “[N]ot all products are appropriate for all press ure ulcers. Wound characteristics should be assessed throughout the healing process to assure that the treatmen ts and dressings being used are appropriate to the nature of the wound.” The facility should review its formula ry for wound care products and make sure that the products are used properly. To accomplish this goal, a restri cted formulary may be advantageous, with in-services for physicians and nurses on appropriate use. Efforts shou ld be made to keep these products in stock to avoid delays when treatments are needed.

Was the Ulcer Avoidable?
The new CMS guidelines contain new detailed wording for surveyors to define whether an ulcer was avo idable or unavoidable. In addition, the investigative protocols present detailed instructions for inquiry into wound prevention, interventions, care plan revisions, and staff interviews to determine citations. The new CMS definition for “avoidable” is as follows:

“Avoidable” means that the resident developed a pressure u lcer and that the facility did not do one or more of the following: evaluate the resident’s clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, re sident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or re vise the interventions as appropriate.

For ulcers that develop or worsen within the facility, we recommend a comprehensive narrative note that summarizes what was done to prevent the ulcer and/or what was done to stop it from getting worse. This note preferably should be written by the medical director and should incorporate in formation regarding the resident’s underlying medical condition, nutritional status, and advance directives. To facilitate the surveyor’s review, this note should refer to specific dates that interventions were performed a nd where the information can be found.

Reverse Staging and the PUSH Tool
“Reverse staging” and the Pressure Ulcer Scale for Healing (PUSH) Tool are discussed in the new CMS guidelines, and these items bear some clarification and discussion. Experts agree that a wound does not heal in a reverse sequence (i.e., stage IV to stage III to stage II, etc.). The National Pressure Ulcer Advisory Panel (NPUAP) ha s taken the position that once an ulcer has reached an advanced stage, that ulcer should not be “downstaged” as it heals; NPUAP says that in the ulcer documentation, this lesion should be referred to as a “healing stage IV ” rather than downstaging to stages III, II, or I. However, this position is at odds with the requirements of t he RAI User’s Manual Version 2.0, which instructs staff to code ulcers using standard staging criteria. We ther efore recommend that nursing facility staff describe ulcers as they appear and not employ the NPUAP reco mmendation to avoid downstaging. Whatever staging system is used, it should be stated clearly in the facility’s P&P manual.

NPUAP has advocated the use of the PUSH Tool, which offers the advantage of calculating a s ingle numeric value for an ulcer, combining scores for length, width, exudate, and presence of eschar. ⁷ This tool does not supplant regular staging, measurement, and a narrative description of the wound. The PU SH Tool is optional and will require additional flow sheets, education, and training; revision of wound care P& Ps; and QA activities to ensure that the tool is being used correctly. Facilities should carefully consider thi s tool and determine whether it fits with their wound care program.

Nutrition and Hydrat ion
Nutrition and hydration comprise a substantial part of the new CMS guidelines, referencing ot her F-tags including F325 (Nutrition) and F327 (Hydration). The guidelines present a concise review of the impo rtance of nutrition to skin integrity and wound care, and provide an overview of nutritional management, includ ing recommended caloric intake and relevant laboratory tests. The new guidelines send a clear message that the nutritionist cannot take a backseat in the wound care process. Nutritional assessments for residents at risk fo r or having wounds should be timely, with special attention to malnutrition and weight loss, with provision of proper calories and fluids.⁸ Wounds may take a long time to heal, and the nutritionist cannot wait u ntil the next quarterly MDS assessment to re-assess the resident. We recommend that the nutritionist engage dir ectly with wound care personnel. Also, lines of communication between the nutritionist and physician should be strengthened.

Resident Choice and Advance Directives
The new CMS guideline s broaden the scope of pressure ulcer care by including issues of resident choice and advance directives. The g uidelines recognize the right of the nursing home resident to make informed choices and refuse treatment. Facil ities now are mandated to discuss the resident’s condition, treatment, expected outcomes, and consequences of r efusing treatment with either the resident or his/her legal representative. This concept is not new, as residen t rights have been woven into the original Nursing Home Reform Amendments passed in 1987. What is new is the ma ndate to apply these concepts directly to ulcer care.

The guidelines also contain instructions that care must be delivered in accordance with residents’ wishes as expressed in valid advance directives. There is a sp ecific notation that a do not resuscitate order is limited only to resuscitative measures and is not applicable to other treatments and services. The incorporation of resident choice and advance directives into the CMS gui delines for wound care strengthen the mandate for resident and family education and inclusion in care plan meet ings. Given the cognitive debility of many residents with pressure ulcers, as well as the complexity of end-of- life care decisions, the role of the social worker in wound care must be emphasized. The social worker is the t eam member who usually invites families to meetings and takes care of advance directives.

Summary
The new CMS guidelines to surveyors for pressure ulcers vastly expand the investigativ e protocols for wounds and add new F-tags for citing facilities for deficiencies in wound care. The guidelines cover risk assessment, documentation, monitoring, nutrition, advance directives, resident choice, and care plan ning. Areas for potential citations are expanded, including pain management, correct use of products, and physi cian involvement. There is now ample incentive to completely review and revise the facility’s P&Ps for wound ca re. The medical director must be part of the team, and resources must be directed at implementing stronger over sight of the wound care program, including QA activities.

For more information, contact Dr. Levine at (212) 253-5601. To send comments to the authors and editors, e-mail levine0905@nursinghomesmagazine.com. To order reprints in quantities of 100 or more, call (866) 377-6454.

References
1. Centers for Medicare & Medicaid Services. Guidance to Surveyors for Long Term Care Facilities. CMS Manual System, Pub. 100 -07 State Operations, Provider Certification, Transmittal 4; November 12, 2004. Available at: www.cms.gov/manuals/pm_trans/r4som.pdf.
2. American Health Care Association. Guidance to Surveyors-Long Term Care Facilities. The Long Term Care Survey. Washingto n D.C.: American Health Care Association, 2002.
3. Seongsook J, Ihnsook J, Younghee L. Validity of pressure ulcer risk assessment scales; Cubbin and Jackson, Braden, and Douglas scale. International Journal of Nursing S tudies 2004;41:199-204.
4. Sprigle S. The NPUAP Support Surface Standards Initiative. Ostomy/Wound Managemen t 2004;50:6-8.
5. Agency for Health Care Policy and Research. Pressure ulcers in adults: Prediction and Prev ention. AHCPR Publication No. 92-0047. Rockville, Md.: U.S. Department of Health and Human Services, 1992.
6 . Popescu A, Salcido RS. Wound pain: A challenge for the patient and the wound care specialist. Advances in Ski n & Wound Care 2004;17:14-20.
7. Pompeo M. Implementing the push tool in clinical practice: Revisions and re sults. Ostomy/Wound Management 2003;49:32-6,38,40 passim.
8. Schols JM, de Jager-v d Ende MA. Nutritional in tervention in pressure ulcer guidelines: An inventory. Nutrition 2004;20:548-53.

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