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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