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Pressure Ulcers Pressure Ulcers The New Investigative Protocols

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Pressure Ulcers Pressure Ulcers The New Investigative Protocols Powered By Docstoc
					   Pressure Ulcers
 The New Investigative
      Protocols


Lynne Condon RNC, BS, RAC-C
Objectives
At the end of the session the attendee will be
able to discuss:
 The difference between avoidable and
  unavoidable pressure ulcers
 The changes that CMS has made to the
  Surveyors investigative protocols
 The importance of accurate assessment and
  follow through by nursing, in prevention and
  treatment of pressure ulcers
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
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:
The facility failed to…
   Evaluate the resident’s          Monitor and evaluate the
    clinical condition and risk       impact of the
    factors                           interventions
   Define and implement             Revise interventions as
    interventions that are            appropriate
    consistent with the
    resident’s needs, goals
    and recognized
    standards of practice
History
   • Revised definitions and added
    clarifications for types of ulcers
     • Including non-pressure
   • Greater in depth definitions for:
     • Cleansing
     • Colonization/Infections
     • Debridement
        • Types
Investigative Protocols
   Surveyor Objectives:
    • Determine if ulcer(s) is avoidable or
      unavoidable; and
    • Determine adequacy of the
      interventions to prevent and treat
      pressure ulcers
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
Investigative Protocols
 Observation
    • Wound site and Treatment
   Preventive measures
    • Positioning
    • Pressure relief
    • RD consult timely
Investigative Protocols
   Does record accurately reflect current
    wound status?
    • Description of site
       • Stage
       • Exudates
       • Necrotic tissue – eschar or slough
       • Erythema or swelling around site
Investigative Protocols
   Debridement
    • Type or form if used
    • If not used when site is clearly in need
     of debridement… why was it not done?
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
    Investigative Protocols
 Interviews
   • Licensed and unlicensed staff
 Record review
    • Concurrent daily review notes
    • Assessment – MDS/RAI
       • Accurate coding
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?
Investigative Protocols
   Record review cont.
      • Did the facility monitor the site and
       note any signs of
       change/progression of the area?
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%




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

				
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