Articles: Medical Topics
New Pressure Ulcer Guidance for Surveyors Helps Clinicians and
Legal Professionals
 Patricia
Iyer MSN RN LNCC is president of Med League Support Services,
an independent legal nurse consulting firm in Flemington, NJ.
She is the editor of Nursing
Home Litigation, Investigation and Case Preparation, Second edition,
to be published in May 2005, and the presenter of a video entitled
Nursing Home
Liability. She is a past president of the American Association
of Legal Nurse Consultants and serves as the Education Committee
Chair.
In November
2004, The Centers for
Medicare and Medicaid Services (CMS) issued guidance
to surveyors involved in nursing homes visits. This report
can be found here
(pdf). Some of the key findings of these changes are
summarized below. The author of this article has added bulleted
comments in italics. Clinicians, attorneys, expert
witnesses, and legal nurse consultants who evaluate pressure
ulcer cases are urged to review the complete CMS document
for all of the pertinent points. The CMS document concludes
with a protocol for surveyors to use to evaluate a pressure
ulcer development in a facility. It serves also as a blueprint
for evaluating liability.
At the time
of the assessment and diagnosis, the clinician is expected to
document the clinical basis of the ulcer (e.g. underlying condition
contributing to the ulceration, ulcer edges and wound bed, location,
shape, condition of surrounding tissues) which permit differentiating
the ulcer type, especially if the ulcer has characteristics consistent
with a pressure ulcer, but is determined not to be one.
- Look
at the initial admission assessment or wound care sheet, if
the facility uses one, for the status of skin on admission.
It is helpful to set up a table to track each site of breakdown,
noting stage, dimensions, drainage, and so on.
The CMS document
defines unavoidable pressure ulcers for the first time. “An
unavoidable pressure ulcer occurs when the facility staff evaluated
the resident’s clinical condition and pressure ulcer risk
factors, defined and implemented interventions that are consistent
with resident needs, goals, and recognized standards of practice,
monitored and evaluated the impact of interventions, and revised
the approaches as appropriate.”
-
Documentation
in the medical record should support that all of these components
were carried out. The reviewer should be aware that documentation
may not reflect actual care. One recent study indicated that
while nurses may be charting that turning is being done every
2 hours, the actual care provided is much less. A study of 16
California long-term care facilities demonstrated that repositioning
was documented as being done every 2 hours in 95% of at risk
residents, but were actually being turned every 3 hours in only
23% of residents at risk, as measured by a wireless movement
monitor.1
The staff
should perform a complete assessment in order to effectively prevent
pressure ulcers and to identify the resident with pressure ulcers.
An admission assessment helps to identify the resident at risk
of developing a pressure ulcer or one who entered with pre-existing
signs. These are defined as a very dark area that is surrounded
by profound redness, swelling, or hardness. This suggests that
deep tissue damage has already occurred.
 This
photo shows a person whose leg is bent back towards her buttock.
She has a Foley catheter going into her bladder. The catheter
tubing has left a mark on her skin due to unrelieved pressure.
The red circle on the skin corresponds to the pink cap on the
catheter. (Image copyright Dr.
Jeffrey Levine, 2005, used with permission for this site only.)
- The
records of the facility that sent the resident to the nursing
home may need to be examined to see if the appropriate standard
of care was delivered. The nursing home can be expected to argue
that the staff inherited the problem from another facility such
as a hospital.
It may be
harder to identify redness in a resident with darkly pigmented
skin. Other signs should be sought, such as bogginess, hardness,
coolness, increased warmth, or skin discoloration.
- Look
for documentation that the staff noted these signs.
A resident
with a pressure ulcer who continues to lose weight either needs
more calories or correction, where possible, of conditions that
are creating a hypermetabolic state. Continuing weight loss and
failure of a pressure ulcer to heal despite reasonable efforts
to improve caloric intake may indicate that the resident is in
a multi-system failure or an end-stage or end-of-life condition
warranting additional assessment of the resident’s overall
condition.
-
Some residents have terminal illnesses, such as undiagnosed
cancer, which causes uncontrollable weight loss. The reviewer
should examine the records for signs that might be consistent
with undiagnosed malignancies, such as unexplained bleeding,
or statements in physician progress notes indicating that the
family or patient declined investigation of suspicious signs
and symptoms.
It is critical
that each resident at risk for hydration deficits or imbalance,
including the resident with a pressure ulcer or at risk of developing
an ulcer, be identified and that hydration needs are addressed.
- Documentation
about fluid intake should be reviewed. Evaluate laboratory results
for evidence of dehydration such as electrolyte abnormalities,
dry mucous membranes, and so on.
Some studies
have found that fecal incontinence may pose a greater threat to
skin integrity than urine, most likely due to bile acids and enzymes
in feces.
- Review
the medical record to determine if the resident was incontinent
of bowel and bladder. Family statements or testimony may indicate
that the resident was often found in soiled sheets or with feces
caked to the skin.
The care plan
for a resident who is reclining and dependent on staff for repositioning
should address position changes to maintain the resident’s
skin integrity. This may include repositioning at least every
2 hours or more frequently depending on the resident’s condition
and tolerance of the tissue load (pressure.)
- Residents
on tube feedings are maintained with the head of the bed elevated
to reduce the risk of aspiration. This puts pressure on the
sacral area. Protective mattresses are important aides in reducing
pressure.
Wheelchairs
are often used for transporting residents, but they may severely
limit repositioning options and increase the risk of pressure
ulcer development. Wheelchairs with sling seats may not be optimal
for prolonged sitting during activities or meals. Available modifications
to the seating can provide a more stable surface and better pressure
reduction.
- Look
for evidence that protective seat cushions were provided by
physical or occupational therapy. Review the medical record
to determine, if possible, how long the resident was sitting
in a wheelchair each day.
The resident’s
heels and elbows are particularly vulnerable to pressure due to
their small surface area. It is important to pay particular attention
to reducing the pressure on these areas.
 This
is a stage III pressure sore on the heel of a foot. The milky
fluid indicates it is infected. The section on the right that
is beige and black consists of dead tissue. This area needs to
be debrided or removed through either a knife or through the use
of chemicals to dissolve the dead tissue. (Image copyright Dr.
Jeffrey Levine, 2005, used with permission for this site only.)
- The medical
record should include documentation of the use of heel protectors
and elevation of the heels while in bed. Heel protectors alone
are not as effective as eliminating pressure through elevation.
Staff should
remain alert on a daily basis to potential changes in the skin
condition. A resident who complains of pain or burning at a site
where there has been pressure should be evaluated.
- Evidence
shows that residents with dementia are able to accurately report
pain, and that pressure sores are painful in all stages.
Components
of assessment of an ulcer include:
Differentiate
the type of ulcer
Determine the ulcer’s stage
Describe and monitor the ulcer’s characteristics
Monitor the progress towards healing
Monitor for potential complications
Determine if the ulcer is infected
Assess, treat, and monitor pain, if present, and
Monitor dressings and treatments.
With each
dressing change or at least weekly (and more often when indicated
by wound complications or changes in wound characteristics), an
evaluation of the pressure ulcer wound should be documented. At
a minimum, documentation should include the date observed and:
Location
and staging
Size, depth, presence, location, and extent of any undermining
or tunneling/sinus tract
Exudate: color, odor and approximate amount
Pain, if present: nature, frequency (episodic or continuous)
Wound bed: color, type of tissue, evidence of healing granulation
tissue) or necrosis (slough or eschar)
Description of wound edges and surrounding tissue
(rolled edges, redness,
hardness/induration, maceration)
If the ulcer
fails to show some evidence of healing within 2-4 weeks, the ulcer
and the resident’s overall condition should be reassessed.
- Evaluate
the plan of care and determine if a wound care team was involved.
Were treatments appropriate to the stage of the ulcer? Was a
dietician involved? Were treatments administered as ordered
or were ones missed?
If photographs
are used, they should be taken in compliance with a protocol that
addresses frequency, consistent distance from the wound, type
of equipment used, means to assure digital images are accurate
and not modified, inclusion of the resident identification/ulcer
location/dates, and so on within the photographic images, and
parameters for comparison.
- Some
facilities are using the additional precaution of photographing
all pressure ulcers found at the time of admission. The photographs
and documentation establish a baseline to evaluate changes in
skin integrity. Some defense attorneys are discouraging the
use of photographs. Most defense attorneys do not like facilities
to take pictures because they provide graphic demonstration
of the injury.
-
Pressure ulcer cases can horrify a jury, making these cases
high risk for the defense. Careful investigation of the medical
record, photographs, and family statements about care can be
helpful in determining if the standard of care was followed.
 This
photo of a nursing home resident was taken by her family members.
This is a stage IV sore on her sacrum, which is the base of the
spine. Muscle and bone are exposed. (Image used with permission
for this site only.)
1.
(back to article)
Bates-Jensen BM. Cadogan M. Osterweil D. Levy-Storms L. Jorge
J. Al-Samarrai N. Grbic V. Schnelle JF. "The Minimum Data
Set Pressure Ulcer indicator: does it reflect differences in care
processes related to pressure ulcer prevention and treatment in
nursing homes?" Journal of the American Geriatrics Society.
51(9):1203-12, 2003.
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