Pressure Ulcers Skin Pressure by nikeborome

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									Skin/Pressure Ulcers

   Implementation Date
  F309 – 483.25 Quality of Care
• 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
                  No change
            F309 – Intent
The facility must ensure that the resident
obtains optimal improvement or does not
deteriorate within the limits of a resident’s
right to refuse treatment, and within the
limits of recognized pathology and the
normal aging process.

                   No change

• Important to differentiate between a
  pressure ulcer and a skin ulcer/wound.
               Arterial Ulcers
• Arterial Ulcer – non-pressure related
  disruption or blockage of the arterial blood
• Underlining cause may be:
  –   Moderate to severe peripheral vascular disease.
  –   Generalized arteriosclerosis.
  –   Inflammatory or autoimmune disorder.
  –   Significant vascular disease elsewhere.
                  Arterial Ulcer
• Characteristics:
   –   Painful
   –   Distal portion of the lower extremity
   –   May be over ankle or bony areas of the foot
   –   Wound bed is dry and pale with minimal or no exudate.
   –   Diminished/absent pedal pulse
   –   Cool to touch
   –   Pain/blanching on elevation
   –   Hair loss
   –   Toenail thickening
    Diabetic Neuropathic Ulcer
• Requires the resident to be diagnosed with
  diabetes mellitus and have peripheral
• Characteristically occurs on the foot.
    Venous Insufficiency Ulcer
         (Stasis Ulcer)
• Open lesion of the skin and subcutaneous
  tissue of the lower leg usually occurring in
  the pre-tibial area of the lower leg or above
  the medial ankle.
• Most common vascular ulceration.
• Difficult to heal.
• Venous hypertension is a causative factor.
       F314 – 483.25(c) Part 1
           Pressure Sores
• Based on the Comprehensive assessment of
  a resident, the facility must ensure that (1)
  A resident who enters the facility without
  pressure sores does not develop pressure
  sores unless the individual’s clinical
  condition demonstrates that they were
                   No change
               F314 Intent
• Part 1: Residents do not develop pressure
  ulcers unless they are unavoidable.
• Unavoidable:
  – Assessed
  – Care planned
  – Care plan implemented
  – Evaluation of outcomes
  – Care plan revised
Not all pressure ulcers are avoidable
  – Multi system organ failure or end of
    life condition.
  – Refusing care and treatment.
      F314 – 483.25(c) Part 2
          Pressure Sores
A resident having pressure sores receives the
 necessary treatment and services to
 promote healing, prevent infection, and
 prevent new sores from developing.
              F314 – Intent
Part 2: The facility provides care and services
   – Promote healing of current ulcers.
   – Promote prevention.
   – Prevent infection.
   – Prevent development of additional
     pressure ulcers.
• Pressure ulcer – lesion caused by unrelieved
  pressure that results in damage to the
  underlying tissue.

• Friction/shear – contributing factors.
• Assessment (Initial and ongoing)
  – Identify risk factors (the at risk resident
    can develop a pressure ulcer within 2 to 6
    hours of the onset of pressure.)
     • Which can be removed/modified?
  – Identify pre-existing signs (purple or very
    dark area surrounded by profound
    redness, edema, induration, bogginess,
    coolness, increased warmth.)
     Assessment - Risk Factors
• Impaired/decreased mobility and/or functional
• Co morbid conditions
• Drugs (steroids effect healing)
• Impaired blood flow
• Resident refusal
• Cognitive impairment
• Exposure to urinary/fecal incontinence
• Under nutrition, malnutrition, hydration deficits
• A healed ulcer (Stage III and IV)
– Evaluate current skin condition.
– Evaluate underlying medical conditions.
– Consider intrinsic factors do to aging.
   • Decreased subcutaneous tissue
– Evaluate the nature of the pressure to which the
  resident maybe subjected.
   • Pressure intensity
   • Pressure duration
   • Tissue tolerance
         Frequency Suggestion
• Significant number of pressure ulcers
  develop within the first 4 weeks of
  –   Use a standardize risk assessment on admission
  –   Repeat weekly for the first 4 weeks
  –   Repeat quarterly
  –   Repeat whenever there is a change
• Comprehensive assessment provides the
  basis for defining approaches.
• Effective prevention and treatment are
  based upon consistently providing routine
  and individualized interventions.
• Care plan with relevant goals and
  approaches to stabilize/improve co-
• Resident choice – discuss choices with
  resident and/or family.
• Advanced Directive
   – Does not prevent the facility from giving
     supportive, pertinent care.
• Basic/Routine care:
  – Redistribute pressure (repositioning, protecting
  – Minimize exposure to moisture, keep skin
  – Provide appropriate pressure redistributing ,
    support surfaces
  – Provide non-irritating surfaces
  – Maintain or improve nutrition and hydration
    status, where feasible
• Repositioning
  – Resident may need supportive devices to
    facilitate position changes.
  – At least every 2 hours or more frequently
    – dependent on tissue tolerance.
  – Elevating the chair back/head on bed
    greater then 30 degrees is comparable to
• Teach a resident to shift weight every 15
  minutes while sitting in chair.
• Wheelchairs with sling seats are not optimal
  for prolonged sitting.
• Momentary pressure relief does not allow
  sufficient capillary refill and tissue
• Support Surfaces and Pressure Redistribution
   – Distribute load over a surface or contact area.
      • Pressure reduction (reduction of interface
        pressure, not necessarily below capillary
        closure pressure)
      • Pressure relief (reduction of interface pressure
        below capillary closure pressure)
   – Effectiveness needs to be evaluated on an
     ongoing basis.
• Static pressure redistribution devices (solid
  foam, convoluted foam, gel mattress)
  – Used for resident at risk for pressure ulcer
    development or delayed healing.
    Does not eliminate the necessity for periodic
• Dynamic pressure reduction surfaces
  – Used when resident cannot assume a variety of
    positions without bearing weight on a pressure
  – Used when resident completely compresses a
    static device that has retained its original
  – Pressure ulcer is not healing and it is
    determined pressure may be contributing to the
    delay in healing.

• Friction – mechanical force exerted on the
  skin that is dragged across any surface.

• Shearing – interaction of both gravity and
  friction against the surface of the skin.
• Weight reflects a balance between intake and
  utilization of energy.
• Consider:
   –   Severity of the nutritional compromise
   –   Rate of weight loss or appetite decline
   –   Probable cause
   –   Prognosis
   –   Projected clinical course
   –   Resident wishes and goals
• Resident who is nutritionally compromised
  and has a pressure ulcer:
  – Protein intake 1.2 to 1.5 gm/kg body weight
  – Simple multivitamin
  – Clinical observation
     • Some laboratory tests may help – no laboratory test
       is specific or sensitive enough to warrant
       serial/repeated testing. (A low albumin level
       combined with the facility’s lack of supplementation
       is not sufficient to cite a pressure ulcer deficiency.)
• Debridement
• Removal of devitalized/necrotic tissue and foreign
  matter from a wound – improve/facilitate healing.
   –   Autolytic debridement
   –   Enzymatic (chemical) debridement
   –   Mechanical debridement
   –   Sharp or surgical debridement
   –   Maggot debridement therapy
• Pain Control
• Pain:
   – Integral component of pressure ulcer prevention
     and management.
   – Eliminate the cause
   – Provide analgesia
• Assessing pain in the cognitively impaired.
• Individual perception.
Current literature reports that all Stage II, III,
and IV are colonized with bacteria but may
not be infected.
• Colonized – presence of bacteria without
  the signs and symptoms of an infection.

• Infected – presence of bacteria in sufficient
  quantities to overwhelm the defenses of
  viable tissue and produce the signs and
  symptoms of infection.
• Classified as infected:
  – If signs and symptoms of infection are present
  – Wound culture contains 100,000 or greater
    micro-organisms per gram of tissue.

• Findings such as elevated white blood cell
  count, bacteremia, sepsis or fever may
  signal pressure ulcer infection or co-existing
  infection from a difference source.
• At least daily – evaluate and document.
   – Evaluate the ulcer and status of area surrounding the
   – Evaluate the dressing
   – Evaluate for complications and pain.
• At least weekly evaluate and document:
   – Location and staging
   – Size
   – Exudate
   – Pain
   – Wound bed
   – Description of wound edges and surrounding tissue
• Assessing ulcer:
  – Differentiate the type of ulcer (pressure or non-
  – Stage
  – Describe/Monitor characteristics
  – Monitor progress
  – Watch for infection
  – Assess, treat and monitor pain
  – Monitor dressing and treatments
• Eschar – thick, leathery, (black or brown
  color) dead/devitalized tissue. May be
  loose or firmly adhered to the wound.

• Slough – Necrotic tissue in the process of
  separating from the viable portions of the
  body. Soft, moist, light in color.

• Exudate - any fluid that has been forced our
  of the tissue because of inflammation or
  – Purulent exudate/drainage/discharge – Product
    of inflammation – contains pus.
  – Serous drainage or exudate – watery, clear,
    yellowish/tan /pink in color that separates from
    the blood and presents as drainage.
• Granulation Tissue - Pink-red moist tissue
  that fills al open wound when it starts to
  heal. Contains new blood vessels, collagen,
  fibroblast, and inflammatory cells.

• Undermining – destruction of tissue or
  ulceration extending under the skin edges
  (margins) so that the pressure ulcer is larger
  at the base than at the skin surface.
• Tunneling – passageway of tissue
  destruction under the skin surface that has
  an opening at the skin level.

• Sinus Tract – Cavity or channel underlying
  a wound that involves an area larger than
  visible surface of the wound.
• Staging:
  –   Stage I
  –   Stage II
  –   Stage III
  –   Stage IV
• If eschar and necrotic tissue covering and
  preventing adequate staging code as Stage

• Clean pressure ulcer with adequate blood
  supply and innervation should show
  evidence of stabilization or some healing
  within 2-4 weeks.
• If no evidence of progress toward healing
  within 2-4 weeks – reassess.
    F314 – Investigative Protocol
          Pressure Ulcers
• Objectives:
  – To determine if the identified pressure(s) ulcer
    is avoidable or unavoidable.
  – To determine the adequacy of the facility’s
    intervention and efforts to prevent and treat
    pressure ulcers.
      F314 Investigative Protocol

• Use
  – Sampled resident having, or at risk of
    developing a pressure ulcer.
• If not a pressure ulcer – do not proceed with
  this protocol.
     F314 Investigative Protocol

• Procedures:
  – Briefly review the assessment, care plan and

• Observation
• Interview
• Record review
      F314 Investigative Protocol

1. Observation:
   – Do staff consistently implement the care
     plan over time and across various shifts?
      • Note/follow-up on deviations from the
        care plan.
      • Note/follow-up on potential negative
      F314 Investigative Protocol

• Look for erythematic or color changes on
  areas such as the sacrum, buttocks,
  trochanters, posterior thigh, popliteal area,
  heels when moved off the area:
   – If noted – return ½ to ¾ hours later
     determine if characteristics persist.
   F314 Investigative Protocol
  Potential Negative Outcomes
– If changes persist and exhibit tenderness,
  hardness or alteration in temperature
  from surrounding skin – interview staff:
   • Positioning schedule.
   • Policy and procedure for addressing a
     Stage I pressure ulcer.
F314 Investigative Protocol Potential
        Negative Outcome
• Look for previously unidentified open areas.
• Look at resident positioning. Is the resident
  positioned to avoid pressure on an existing
  pressure ulcer?
• Does the facility prevent shearing or friction
  during transfers, elevation and repositioning?
• Are pressure-redistribution devices in place and
       F314 Investigative Protocol

• Observe existing ulcer and wound care.
      • Characteristics of the wound and surrounding tissue.
      • Type of debridement.
      • Treatment and infection control practices reflect
        current standards of practice.
      • Steps taken to clean/protect from contamination by
        urine or fecal incontinence.
• Does the clinical record reflect the current status
  of the ulcer?
     F314 Investigative Protocol

• Unable to observe due to dressing protocol:
  – Inspect surrounding tissues
  – May request the dressing be removed if other
    information suggests a possible
    treatment/assessment problem
      F314 Investigative Protocol

• Resident expresses pain related to the ulcer
  or treatment:
  – Was the resident assessed for pain?
  – Were preemptive measures taken?
  – Were the preemptive measures effective?
   F314 Investigative Protocol
2. Interviews
• Resident/family/responsible party:
  – Were they involved in care plan, choices, goals? Do
    interventions reflect their preferences?
  – Are they aware of the approaches being used?
  – Is there presence of pain? How is it managed?
  – If treatment was refused were they counseled on
    alternatives, consequences?
  – Are they aware of the history of the pressure ulcer? The
      F314 Investigative Protocol
• Staff interviews – various shifts:
  – Does the staff have knowledge of prevention
    and treatment?
  – Do the nursing assistants know what, when, and
    to whom to report changes in skin condition?
  – Who monitors for the implementation of the
    care plan?
  – Who monitors treatment, frequency of review
    and evaluation of the ulcer?
     F314 Investigative Protocol

3. Record Review:
   – Documentation should include:
     • Assessment of overall condition
     • Risk factors
     • Presence of existing pressure ulcer
     •F314 Investigative Protocol

• If the resident was admitted or developed an
  ulcer within 1 to 2 days of admission:
  – Review admission documentation (site,
    characteristics, tissue damage due to immobility
    or prior illness, skin condition on day of
    admission, nutritional history, previous
    pressure ulcer.)
     F314 Investigative Protocol

• Resident who subsequently developed or
  has an existing pressure ulcer:
  – Review documentation (wound site,
    characteristics , progress and complications.)
  – If no signs of healing within 2 to 4 weeks was
    the wound/treatment reassessed?
     F314 Investigative Protocol

• Care plan:
  – Is it individualized?
  – Does it address prevention, care, and
  – Are there specific interventions,
    measurable goals, time frames.
      F314 Investigative Protocol

• Revision of care plan:
  – Is staff monitoring resident’s response to
  – Is the care plan revised based on
    resident’s responses, outcomes and
     F314 Investigative Protocol

 If interventions/care provided appears not
   to be consistent with recognized standards
   of practice interview one or more health
   care practitioners/ professionals
   (physician, charge nurse, DON.)
   How was it determined that the chosen
     interventions were appropriate?
   F314 Investigative Protocol
– Are there risks identified with this treatment for
  which there are no interventions?
– Do changes in condition justify additional or
  different interventions?
– How is the effectiveness of the current
  interventions validated?
          Criteria for Compliance
• Resident with acquired pressure sore:
   – Assessed (risk factors identified and skin condition)
   – Developed and implemented a plan of care based on the
     resident needs
   – Monitored and evaluated response to interventions
   – Revised approaches as appropriate
• If not, the pressure ulcer was avoidable. Cite at
          Criteria for Compliance
• Resident admitted with pressure ulcer, non-healing
  pressure ulcer, at risk of developing subsequent
  pressure ulcers:
   – Assessment (risk factors and skin condition)
   – Developed and implemented a plan of care based on
     resident needs
   – Address potential infection
   – Monitor/evaluate response
   – Revise approaches as appropriate
• If not cite at F314.
         F314 Non-compliance

• May include one or more of the following:
  – Failed to accurately or consistently assess.
  – Failed to identify and address risks for
    developing pressure ulcers.
  – Failed to implement preventative interventions
    in accord with the resident’s needs and current
    standards of practice.
         F314 Non-compliance

• Failed to provide clinical justification for
  the unavoidable development or non-
  healing/delayed healing or deterioration of a
  pressure ulcer.
• Failed to provide appropriate interventions,
  care and treatment to an existing pressure
  ulcer to minimize infection and promote
          F314 Non-compliance
• Failed to implement interventions for existing
• Failed to notify physician of residents condition or
  changes in resident’s wound care.
• Failed to adequately implement pertinent infection
  management practices.
• Failed to identify or know how to apply relevant
  policies and procedures for prevention and
     Potential tags for Additional
• F157 - Notification of changes
• F272 - Comprehensive assessment
• F279 - Comprehensive Care Plans
• F280 – Comprehensive Care Plans
• F281 – Services provided in accordance
  with accepted professional standards
• F309 – Quality of care
     Potential tags for Additional
• F353 - Sufficient Staff
• F385 - Physician Supervision
• F501- Medical Director
        Severity Determination

• Key elements for severity determination:
  – 1. Presence of harm/negative outcomes or
    potential for negative outcomes because of lack
    of appropriate treatment and care.
  – 2. Degree of harm (actual or potential) related
    to the non-compliance.
  – 3. The immediacy of correction required.

• Level 4 – Immediate Jeopardy to
  – Facility non-compliance has caused or is likely
    to cause serious injury, harm, impairment,
  – Requires immediate correction
           Examples – Level 4

• Development of avoidable Stage 4.
• Admitted with Stage 4 – no healing or
• Stage 3 or 4 with associated soft tissue or
  systemic infection.
• Extensive failure in multiple areas of
  pressure ulcer care.

• Level 3 – Actual harm.
  – Clinical compromise.
  – Decline.
  – Impact resident’s ability to maintain and/or
    reach highest practicable well-being.
          Examples – Level 3

• Development of avoidable Stage 3.
• Development of recurrent or multiple
  avoidable Stage 2.
• Failure to implement the comprehensive
  care plan for a resident who has a pressure

• Level 2
  – Minimal discomfort.
  – Potential to compromise ability for maintain or
    reach highest practicable level of well being.
  – Potential for greater harm.
           Examples – Level 2

• Development of single avoidable Stage 2
  that is receiving appropriate treatment.
• Development of avoidable Stage 1.
• Failure to implement an element of the care
  plan – no evidence of decline.
• Failure to recognize or address the potential
  for developing a pressure ulcer.
               Severity – Level 1

• No actual harm with potential for minimal
  – Does not apply to this regulatory requirement.
             F314 - Overview

• Research into appropriate practices for
  pressure ulcer prevention and healing.
  – The Clinical Practice Guidelines
     • Guideline #15
  – The National Pressure ulcer Advisory Panel
             F314 - Overview
– The American Medical Directors Association (AMDA)
– The Quality Improvement Organization
– The Wound, Ostomy, and Continence Nurses Society
– The American Geriatrics Society guideline “The
  Management of Persistent Pain in Older Persons.”

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