New Pressure Ulcer Guideline
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.
- 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.
- 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.
