Pressure Ulcers The New Investigative Protocols

1. Pressure Ulcers The New Investigative Protocols Lynne Condon RNC, BS, RAC-C

3. 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

4. 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:

5. The facility failed to� Evaluate the resident�s clinical condition and risk factors Define and implement interventions that are consistent with the resident�s needs, goals and recognized standards of practice Monitor and evaluate the impact of the interventions Revise interventions as appropriate

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

7. Investigative Protocols Surveyor Objectives: Determine if ulcer(s) is avoidable or unavoidable; and Determine adequacy of the interventions to prevent and treat pressure ulcers

8. 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

9. Investigative Protocols Observation Wound site and Treatment Preventive measures Positioning Pressure relief RD consult timely

10. Investigative Protocols Does record accurately reflect current wound status? Description of site Stage Exudates Necrotic tissue � eschar or slough Erythema or swelling around site

11. Investigative Protocols Debridement Type or form if used If not used when site is clearly in need of debridement� why was it not done?

12. 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

13. Investigative Protocols Interviews Licensed and unlicensed staff Record review Concurrent daily review notes Assessment � MDS/RAI Accurate coding

14. 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?

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

16. Data based on most recent update from CMS 5/12/05 16 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%

17. 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%

18. 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

19. 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.

20. 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 individual�s clinical condition demonstrates that they were unavoidable; and

21. 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.

22. 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

23. 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?

24. 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

25. 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?

26. 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

27. Points of Contact Linda Masterson RN, QA Technical Support Team Coordinator 410-402-8008 lmasterson@dhmh.state.md.us William Vaughan RN, OHCQ Chief Nurse 410-402-8140 wvaughan@dhmh.state.md.us Lynne Condon RNC 410-402-8102 lcondon@dhmh.state.md.us Joseph Berman MD 410-402-8007 jberman@dhmh.state.md.us