Protocols by Level of Risk

AT RISK (15-18)*

FREQUENT TURNINGMAXIMAL REMOBILIZATION

PROTECT HEELSMANAGE MOISTURE, NUTRITION

AND FRICTION AND SHEARPRESSURE-REDUCTION SUPPORT SURFACE

IFBED- OR CHAIR-BOUND

* If other major risk factors are present (advanced age, fever, poor dietary intake of protein,

diastolic pressure below 60, hemodynamic instability) advance to next level of risk

MANAGE MOISTURE

USE COMMERCIAL MOISTURE BARRIERUSE ABSORBANT PADS OR DIAPERS THAT

WICK & HOLD MOISTUREADDRESS CAUSE IF POSIBLE

OFFER BEDPAN/URINAL AND GLASS OF WATER IN CONJUNCTION WITH TURNING

SCHEDULES

MODERATE RISK (13-14)*

TURNING SCHEDULEUSE FOAM WEDGES FOR 30! LATERAL

POSITIONINGPRESSURE-REDUCTION SUPPORT SURFACE

MAXIMAL REMOBILIZATION PROTECT HEELS

MANAGE MOISTURE, NUTRITIONAND FRICTION AND SHEAR

* If other major risk factors present, advance to next level of risk

MANAGE NUTRITION

INCREASE PROTEIN INTAKE INCREASE CALORIE INTAKE TO SPARE

PROTEINS.SUPPLEMENT WITH MULTI-VITAMIN

(SHOULD HAVE VIT A, C & E)ACT QUICKLY TO ALLEVIATE DEFICITS

CONSULT DIETITIAN

HIGH RISK (10-12)

INCREASE FREQUENCY OF TURNINGSUPPLEMENT WITH SMALL SHIFTS

PRESSURE REDUCTION SUPPORT SURFACE USE FOAM WEDGES FOR 30! LATERAL

POSITIONIINGMAXIMAL REMOBILIZATION

PROTECT HEELSMANAGE MOISTURE, NUTRITION

AND FRICTION AND SHEAR

MANAGE FRICTION & SHEAR

ELEVATE HOB NO MORE THAN 30!USE TRAPEZE WHEN INDICATED

USE LIFT SHEET TO MOVE PATIENTPROTECT ELBOWS & HEELS IF BEING

EXPOSED TO FRICTION

VERY HIGH RISK (9 or below)

ALL OF THE ABOVE +

USE PRESSURE-RELIEVING SURFACE IF PATIENT HAS INTRACTABLE PAIN

ORSEVERE PAIN EXACERBATED BY TURNING

ORADDITIONAL RISK FACTORS

*low air loss beds do not substitute for turning schedules

OTHER GENERAL CARE ISSUES

NO MASSAGE OF REDDENED BONY PROMINENCES

NO DO-NUT TYPE DEVICESMAINTAIN GOOD HYDRATION

AVOID DRYING THE SKIN

© Barbara Braden, 2001

BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK Patient=s Name _____________________________________ Evaluator=s Name________________________________ Date of Assessment

SENSORY PERCEPTION ability to respond meaning- fully to pressure-related discomfort

1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of con-sciousness or sedation. OR limited ability to feel pain over most of body

2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over 2 of body.

3. Slightly Limited Responds to verbal com- mands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort..

MOISTURE degree to which skin is exposed to moisture

1. Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

2. Very Moist Skin is often, but not always moist. Linen must be changed at least once a shift.

3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day.

4. Rarely Moist Skin is usually dry, linen only requires changing at routine intervals.

ACTIVITY degree of physical activity

1. Bedfast Confined to bed.

2. Chairfast Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

3. Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair

4. Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours

MOBILITY ability to change and control body position

1. Completely Immobile Does not make even slight changes in body or extremity position without assistance

2. Very Limited Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

3. Slightly Limited Makes frequent though slight changes in body or extremity position independently.

4. No Limitation Makes major and frequent changes in position without assistance.

NUTRITION usual food intake pattern

1. Very Poor Never eats a complete meal. Rarely eats more than a of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO and/or maintained on clear liquids or IV=s for more than 5 days.

2. Probably Inadequate Rarely eats a complete meal and generally eats only about 2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding

3. Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs

4. Excellent Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

FRICTION & SHEAR

1. Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction

2. Potential Problem Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.

3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.

8 Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved Total Score

State Operations Manual Appendix PP - Guidance to Surveyors for

Long Term Care Facilities Table of Contents

(Rev. 11-22-17)

Transmittals for Appendix PP

INDEX

§483.5 Definitions§483.10 Resident Rights§483.12 Freedom from Abuse, Neglect, and Exploitation§483.15 Admission Transfer and Discharge Rights§483.20 Resident Assessment§483.21 Comprehensive Person-Centered Care Plans§483.24 Quality of Life§483.25 Quality of Care§483.30 Physician Services§483.35 Nursing Services§483.40 Behavioral health services§483.45 Pharmacy Services§483.50 Laboratory Radiology and Other Diagnostic Services§483.55 Dental Services§483.60 Food and Nutrition Services§483.65 Specialized Rehabilitative Services§483.70 Administration§483.75 Quality Assurance and Performance Improvement§483.80 Infection Control§483.85 Compliance and Ethics Program§483.90 Physical Environment§483.95 Training Requirements

F658 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§483.21(b)(3) Comprehensive Care PlansThe services provided or arranged by the facility, as outlined by the comprehensive care plan,must—

(i) Meet professional standards of quality.

INTENT §483.21(b)(3)(i) The intent of this regulation is to assure that services being provided meet professional standards of quality.

GUIDANCE §483.21(b)(3)(i) “Professional standards of quality” means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency. Recommended practices to achieve desired resident outcomes may also be found in clinical literature. Possible reference sources for standards of practice include:

• Current manuals or textbooks on nursing, social work, physical therapy, etc.• Standards published by professional organizations such as the American Dietetic

Association, American Medical Association, American Medical Directors Association,American Nurses Association, National Association of Activity Professionals, NationalAssociation of Social Work, etc.

• Clinical practice guidelines published by the Agency for Healthcare Research andQuality.

• Current professional journal articles.

NOTE: Although Federal requirements dictate the completion of RAI assessments according to certain time frames, standards of good clinical practice dictate that the clinical assessment process is more fluid and should be ongoing. The lack of ongoing clinical assessment and identification of changes in condition, to meet the resident’s needs between required RAI

assessments should be addressed at §483.35 Nursing Services, F726 (competency and skills to identify and address a change in condition), and the relevant outcome tag, such as §483.12 Abuse, §483.24 Quality of Life, §483.25 Quality of Care, and/or §483.40 Behavioral Health.

PROCEDURES AND PROBES §483.21(b)(3)(i) There is no requirement for the surveyor to cite a reference or source (e.g., current textbooks, professional organizations or clinical practice guidelines) for the standard of practice that has not been followed related to care and services provided within professional scopes of practice, such as failure of nursing staff to assess a change in the resident’s condition. However, in cases where the facility provides a reference supporting a particular standard of practice for which the surveyor has concerns, the surveyor must provide evidence that the standard of practice the facility is using is not up-to-date, widely accepted, or supported by recent clinical literature. Such evidence should include a citation for the reference or source (e.g., current textbooks, professional organizations or clinical practice guidelines) for the current standard of practice from which facility deviated.

If a negative or potentially negative resident outcome is determined to be related to the facility’s failure to meet professional standards and the team determines a deficiency has occurred, it should also be cited under the appropriate quality of care or other relevant requirement. For example, if a resident develops a pressure injury because the facility’s nursing staff failed to provide care in accordance with professional standards of quality, the team should cite the deficiency at both F658 and F686 (Skin Integrity).

• Do the services provided or arranged by the facility, as outlined in the comprehensivecare plan, reflect accepted standards of practice?

• Are the references for standards of practice, used by the facility, up to date, and accuratefor the service being delivered?

KEY ELEMENTS OF NONCOMPLIANCE: To cite deficient practice at F658, the surveyor's investigation will generally show that the facility did one or more of the following:

• Provided or arranged for services or care that did not adhere to accepted standards ofquality;

• Provided a service or care when the accepted standards of quality dictate that the serviceor care should not have been provided;

• Failed to provide or arrange for services or care that accepted standards of qualitydictate should have been provided.

F684 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§ 483.25 Quality of careQuality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following:

INTENT To ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident’s preferences, goals for care and professional standards of practice that will meet each resident’s physical, mental, and psychosocial needs.

DEFINITIONS “Highest practicable physical, mental, and psychosocial well-being” is defined as the highest possible level of functioning and well-being, limited by the individual’s recognized pathology and normal aging process. Highest practicable is determined through the comprehensive resident assessment and by recognizing and competently and thoroughly addressing the physical, mental or psychosocial needs of the individual.

“Hospice Care” means a comprehensive set of services described in Section 1861(dd)(l) of the Act, identified and coordinated by an interdisciplinary group (IDG) to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care. (42 CFR §418.3)

“Palliative care” means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice. (§418.3)

“Terminally ill” means that the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course. (§418.3)

GUIDANCE NOTE: Although Federal requirements dictate the completion of RAI assessments according to certain time frames, standards of good clinical practice dictate that the clinical assessment process is more fluid and should be ongoing. The lack of ongoing clinical assessment and identification of changes in condition, to meet the resident’s needs between required RAI assessments should be addressed at §483.35 Nursing Services, F726 (competency and skills to identify and address a change in condition), and the relevant outcome tag, such as §483.12 Abuse, §483.24 Quality of Life, §483.25 Quality of Care, and/or §483.40 Behavioral Health. Use guidance at F684 for review of concerns which have caused or have a potential to cause a negative outcome to a resident’s physical, mental, or psychosocial health or well-being that is not specifically addressed by any other tag at §483.25. Additionally, F684 contains guidance for end of life and hospice care. Nursing homes must place priority on identifying what each resident’s highest practicable well-being is in each of the areas of physical, mental and psychosocial health. Each resident’s care plan must reflect person-centered care, and include resident choices, preferences, goals, concerns/needs, and describe the services and care that is to be furnished to attain or maintain, or improve the resident’s highest practicable physical, mental and psychosocial well-being. For concerns related to the resident’s comprehensive care plan, see F656, §483.21(b) Comprehensive Care Plans. The following sections describe some, but not all of the care needs that are not otherwise covered in the remaining tags of §483.25, Quality of Care.

I. Review of a Resident with Non Pressure-Related Skin Ulcer/Wound. Residents may develop various types of skin ulceration. At the time of the assessment and diagnosis of a skin ulcer/wound, the clinician is expected to document the clinical basis (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. This section differentiates some of the different types of skin ulcers/wounds that are not considered to be pressure ulcers. NOTE: Guidance regarding pressure ulcers is found at 42 CFR 483.25 (b)(1)F686 Skin

Integrity – Pressure Ulcers. Use this tag F684 for issues regarding non-pressure related skin ulcers/wounds. Kennedy Terminal Ulcers are considered to be pressure ulcers that generally occur at the end of life. For concerns related to Kennedy Terminal Ulcers, refer to F686, §483.25(b) Pressure Ulcers.

• Arterial Ulcer: An arterial ulcer is ulceration that occurs as the result of arterial

occlusive disease when non-pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis. Inadequate blood supply to the extremity may initially present as intermittent claudication. Arterial/Ischemic ulcers may be present in individuals with moderate to severe peripheral vascular disease, generalized

arteriosclerosis, inflammatory or autoimmune disorders (such as arteritis), or significant vascular disease elsewhere (e.g., stroke or heart attack). The arterial ulcer is characteristically painful, usually occurs in the distal portion of the lower extremity and may be over the ankle or bony areas of the foot (e.g., top of the foot or toe, outside edge of the foot). The wound bed is frequently dry and pale with minimal or no exudate. The affected foot may exhibit: diminished or absent pedal pulse, coolness to touch, decreased pain when hanging down (dependent) or increased pain when elevated, blanching upon elevation, delayed capillary fill time, hair loss on top of the foot and toes, toenail thickening;

• Diabetic Neuropathic Ulcer: A diabetic neuropathic ulcer requires that the resident be diagnosed with diabetes mellitus and have peripheral neuropathy. The diabetic ulcer characteristically occurs on the foot, e.g., at mid-foot, at the ball of the foot over the metatarsal heads, or on the top of toes with Charcot deformity ; and

• Venous or Stasis Ulcer: A venous ulcer (previously known as a stasis ulcer) is an open lesion of the skin and subcutaneous tissue of the lower leg, often occurring in the lower leg around the medial ankle. Venous ulcers are reported to be the most common vascular ulceration and may be difficult to heal, may occur off and on for several years, and may occur after relatively minor trauma. The ulcer may have a moist, granulating wound bed, may be superficial, and may have minimal to copious serous drainage unless the wound is infected. The resident may experience pain that may increase when the foot is in a dependent position, such as when a resident is seated with her or his feet on the floor. Recent literature implicates venous hypertension as a causative factor. Venous hypertension may be caused by one (or a combination of) factor(s) including: loss of (or compromised) valve function in the vein, partial or complete obstruction of the vein (e.g., deep vein thrombosis, obesity, malignancy), and/or failure of the calf muscle to pump the blood (e.g., paralysis, decreased activity). Venous insufficiency may result in edema and induration, dilated superficial veins, dry scaly crusts, dark pigmented skin in the lower third of the leg, or dermatitis. The pigmentation may appear as darkening skin, tan or purple areas in light skinned residents and dark purple, black or dark brown in dark skinned residents. Cellulitis may be present if the tissue is infected.

II. Review of a Resident at or Approaching End of Life and/or Receiving Hospice Care

and Services Assessment The resident must receive a comprehensive assessment to provide direction for the development of the resident’s care plan to address the choices and preferences of the resident who is nearing the end of life. In addition, in order to promote the physical, mental, and psychosocial well-being of a resident who is approaching the end of life, the facility and the resident’s attending physician/practitioner, should, to the extent possible:

• Identify the resident’s prognosis and the basis for that prognosis; and • Initiate discussions/considerations regarding advance care planning and resident choices

to clarify goals and preferences regarding treatment including pain management and symptom control, treatment of acute illness, and choices regarding hospitalization.

Care Plan

The care plan must be based upon the resident assessment, choices and advance directives, if any. As the resident’s status changes, the facility, attending practitioner and the resident representative, to the extent possible, must review and/or revise care plan goals and treatment choices. Based upon the resident’s assessment, the care plan may include, but is not limited to addressing:

• Oral Care - The care plan should include the provision of ongoing, consistent oral care including interventions, as necessary to provide comfort and prevent complications associated with dry mucous membranes and compromised dentition. (For concerns related to the provision of oral hygiene, refer to F676 or F677 - Activities of Daily Living, and for concerns related to dental care, refer to F790 and F791 - Dental Services.);

• Skin Integrity – The care plan should include, for a resident who has skin integrity issues or a pressure injury or is at risk of developing a pressure injury, approaches in accordance with the resident's choices, including, to the extent possible, attempting to improve or stabilize the skin integrity/tissue breakdown and to provide treatments if a pressure injury is present. (For concerns related to pressure injuries, refer to F686.);

• Medical Treatment/Diagnostic Testing - The resident and his/her representative and the attending practitioner may, based on resident choices/directives, make decisions on whether to continue medications, treatments and/or diagnostic tests. This must be included in the resident’s record. (For concerns related to choice, care planning decisions and right to discontinue treatments, refer to F552 and F553.);

• Symptom Management - Symptom management may include controlling nausea, vomiting, uncomfortable breathing, agitation, and pain. Symptom management may include both pharmacological and nonpharmacological interventions consistent with the resident’s choices and goals for comfort, dignity and desired level of alertness. (For concerns related to medications, refer to F758 psychotropic medications and F757 unnecessary medications.);

• Nutrition and Hydration- The resident may experience a decline in appetite or have difficulty eating or swallowing. Care plan interventions, regarding nutrition/hydration, must be based upon the resident’s assessment, disease processes, and resident choices/directives and include amount, type, texture and frequency for food and fluids. Dietary restrictions and/or weight measurements may be revised/discontinued based upon resident/representative and attending practitioner decisions, and must be included in the medical record. If the resident’s condition has declined to the point where he/she may no longer swallow food or fluids, the determination of whether to use artificial nutrition/hydration, based upon resident choices/directives, is made by the resident/ representative and the attending practitioner, and consistent with applicable State law and regulation. (For concerns related to nutrition, refer to F692, for concerns related to nutrition/hydration, and for concerns related to feeding tubes, refer to F693.); and/or

• Activities/Psychosocial Needs - Care plan interventions for activities must be based on the resident’s assessment and include the resident’s choices, personal beliefs, interests, ethnic/cultural practices and spiritual values, as appropriate. In addition, the resident’s assessment may identify psychosocial needs, such as fear, loneliness, anxiety, or depression. Interventions to address the needs must be included in the plan of care. (For concerns related to the provision of activities, refer to F679. For concerns regarding medically related social services, refer to F745.)

For concerns related to developing and implementing the care plan, refer to F656, Comprehensive Care Plans; and for revision of care plans refer to F657, Comprehensive Care Plan Revision.

Resident Care Policies The facility in collaboration with the medical director must develop and implement resident care policies that are consistent with current professional standards of practice for not only pain management and symptom control, but for assessing residents’ physical, intellectual, emotional, social, and spiritual needs as appropriate. In addition, if the facility has a written agreement with a Medicare-certified hospice, the policies must identify the ongoing collaboration and communication processes established by the nursing home and the hospice. (Refer to F841 - §483.70(h) Medical Director, or for the written agreement, to F849, §483.70(o) HospiceServices)

NOTE: If the resident has elected or is revoking the Medicare hospice benefit, a Significant Change in Status Assessment (SCSA) must be conducted as noted in the “Long Term Care Facility Resident Assessment Instrument User’s Manual” (Version 3.0) Chapter 2:

• If a resident was admitted on the hospice benefit (i.e. the resident is coming into thefacility having already elected the hospice benefit), the facility completes the requiredMDS admission assessment;

• If a terminally ill resident elects the hospice benefit after admission, a SCSA must beperformed regardless of whether an MDS assessment was recently conducted on theresident. This is to ensure a coordinated care plan between the hospice and nursing homeis in place; and

• A SCSA is required to be performed when a resident is receiving hospice services anddecides to discontinue those services (revocation of the hospice benefit). (Refer to F637significant change in status assessment)

Hospice Care and Services Provided by a Medicare-certified Hospice Hospice care and services are based upon a written agreement between the nursing home and the Medicare-certified hospice (hereafter referred to as hospice or hospice services). (See F849 - Hospice Services). This section discusses the collaborative services provided by the nursinghome and the hospice for a resident who is receiving hospice care and services.

A nursing home resident at the end of life may choose to elect the Medicare hospice benefit, or may choose to continue to receive the care and services provided by the nursing home. The resident considering election of the hospice benefit must meet the hospice eligibility requirements. According to 42 CFR §418.20, in order to be eligible to elect hospice care under Medicare, an individual must be -

(a) Entitled to Part A of Medicare; and(b) Certified as being terminally ill in accordance with §418.22.

NOTE: Hospice is also an optional state plan benefit in the Medicaid program. If a resident who receives Medicaid chooses to elect the hospice benefit, the physician must provide written certification that the individual is terminally ill. (Refer to SSA Sec. 1905(o)(1)(A). [42 U.S.C.

1396d(o)(1)(A)]) If the resident is eligible for both Medicare and Medicaid, he/she must elect the hospice benefit simultaneously under both programs; and if the resident chooses to revoke the hospice benefit, he/she must revoke the benefit simultaneously under both of the programs.

There is no requirement that a nursing home offer hospice services. Although a resident may meet the eligibility requirements and may choose to elect the hospice benefit, the nursing home may or may not have an arrangement with a hospice to provide hospice care and services. If the nursing home has an agreement with a hospice, it must, consistent with F552, inform each resident before or at the time of admission, and periodically during the resident’s stay, of hospice services available in the nursing home.

If a nursing home allows one or more hospice providers to provide services, there must be a written agreement between each hospice and the nursing home that describes their responsibilities prior to the hospice initiating care for the resident. (For the written agreement refer to F849 - Hospice Services.)

If the resident chooses to elect the hospice benefit, but has not chosen a hospice provider, and the nursing home does not have an agreement with a hospice provider:

• If the resident wishes, the nursing home must assist the resident with a transfer to anotherfacility or appropriate setting where hospice services are provided; or

• The nursing home may choose to establish a written agreement with a hospice.

Coordinated Care Plan The nursing home retains primary responsibility for implementing those aspects of care that are not related to the duties of the hospice. It is the nursing home’s responsibility to continue to furnish 24-hour room and board care, meeting the resident’s personal care and nursing needs. The facility’s services must be consistent with the care plan developed in coordination with the hospice, and the facility must offer the same services to its residents who have elected the hospice benefit as it furnishes to its residents who have not elected the hospice benefit. Therefore, the nursing home resident should not experience any lack of services or personal care because of his or her status as a hospice patient. This includes what would normally be provided to a resident in the nursing home, including but not limited to the following: conducting the comprehensive assessments which includes the Resident Assessment Instrument (RAI), providing personal care, activities, medication administration, required physician visits, monthly medication regimen review, support for activities of daily living, social services as appropriate, nutritional support and services, and monitoring the condition of the resident. The facility is required to develop and update the care plan in accordance with Federal, State or local laws governing the facility.

The hospice retains primary responsibility for the provision of hospice care and services, based upon the resident’s assessments, including but not limited to the following: providing medical direction and management of the resident; nursing,(including assigning a hospice aide as needed to support the resident’s ongoing care); counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and

related conditions; and all other hospice services that are necessary for the care of the resident’s terminal illness and related conditions. See 42 C.F.R. §418.112(c)(6).

NOTE: If there is an issue related to the provision of care by the hospice, the survey team may request the written agreement and review to see the steps the nursing home has taken to resolve the resident care issues. The written agreement should include how differences are resolved between the nursing home and the hospice, and the nursing home and hospice liaisons may need to be interviewed regarding the identified concerns. If there are concerns related to the provision of care based upon the failure of the implementation of the written agreement or the lack of a written agreement, refer to F849.

The resident/representative must be included in the development of the care plan, which must reflect the resident’s choices to the extent possible. In order to address communication regarding the resident’s care between the nursing home and the hospice, the nursing home must designate a staff person to participate in the ongoing communication and include the resident representative in decision-making. The nursing home should provide the name of the designated staff member/or designee to the resident/representative for ongoing communication regarding care or concerns. (Refer to F849 - Designated member of Interdisciplinary Group (IDG))

In order to provide continuity of care, the hospice, nursing home, and resident/representative must collaborate in the development of a coordinated care plan which includes, but is not limited to, the following:

• Resident/representative choices regarding care;• The hospice philosophy of care and all services necessary for the palliation and

management of the terminal illness and related conditions;• Measurable goals and interventions based on comprehensive and ongoing assessments;• Interventions that address, as appropriate, the identification of timely, pertinent non-

pharmacologic and pharmacological interventions to manage pain and other symptomsof discomfort;

• The hospice portion that governs the actions of the hospice and describes the servicesthat are needed to care for the resident;

• Identification of the services the nursing home will continue to provide; and• The identification of the provider responsible for performing specific services/functions

that have been agreed upon.

The structure of the care plan is established by the nursing home and the hospice. The care plan may be divided into two portions, one maintained by the nursing home and the other maintained by the hospice. The nursing home and the hospice must be aware of the location and content of the coordinated care plan (which includes the nursing home portion and the hospice portion) and the plan must be current and internally consistent in order to assure that the needs of the resident for both hospice care and nursing home care are met at all times. Any changes to the plan(s) must be discussed and approved by the nursing home, hospice staff and, to the extent possible, the resident and/or representative.

As the condition of the resident declines, the hospice and nursing home must continue a joint collaborative effort, which includes ongoing communication with and input from the resident/

representative, to assure that the care provided addresses concerns as identified in the ongoing assessments.

Physician Services When a hospice patient is a resident of a nursing home, that resident’s hospice care plan must be established and maintained in consultation with the resident’s attending physician/practitioner, representatives of the nursing home and the resident/representative, to the extent possible. (See F710 – Physician supervision of care) In a nursing home, a physician’s assistant may not act as the hospice attending physician, however, the resident’s attending physician at the nursing home may delegate tasks to a physician’s assistant. See F714 – physician delegation of tasks.

NOTE: For informational purposes, the definition of an attending physician as identified in the hospice federal regulations is provided below. This clarifies that a doctor of medicine, osteopathy or nurse practitioner, if meeting the listed requirements, may function as the “attending physician” in a hospice. The hospice regulations do not provide for a physician assistant to function in this category.

§418.3 Definitions. For the purposes of this part — “Attending physician” means a —(1)(i) Doctor of medicine or osteopathy legally authorized to practice medicine andsurgery by the State in which he or she performs that function or action; or(ii) Nurse practitioner who meets the training, education, and experience requirements asdescribed in §410.75 (b) of this chapter.(2) Is identified by the individual, at the time he or she elects to receive hospice care, ashaving the most significant role in the determination and delivery of the individual'smedical care.

Communication Nursing home staff must immediately contact and communicate with the hospice staff regarding any significant changes in the resident’s status, clinical complications or emergent situations. These situations may include but are not limited to changes in cognition or sudden unexpected decline in condition, a fall with a suspected fracture or adverse consequences to a medication or therapy, or other situations requiring a review or revision to the care plan. The immediate notification to hospice does not change the requirement that a nursing home also immediately notify the resident’s attending physician/practitioner and the family resident representative of significant changes in condition or a need to change the care plan. (Refer to F580 - Notification of Changes) Prior to care plan or order changes, the hospice and the resident’s attending physician/practitioner may need to collaborate to address this change and to assure the resident’s immediate needs and treatment decisions are met, including situations which could require a potential transfer to an acute care setting. This decision making must be consistent with the resident’s wishes. (Refer to F849 - Hospice Services.) Additionally, the communication of necessary information to the receiving provider must include those items required at§483.15(c)(2)(iii), F622.

If there is a conflict between the hospice and the resident’s attending physician/practitioner regarding the care plan, there must be communication between the hospice and the nursing home regarding the issue. This communication should be timely and include the hospice medical

director and the nursing home medical director as well as other pertinent hospice and facility staff, as needed.

The care of the resident receiving hospice services must reflect ongoing communication and collaboration between the nursing home and the hospice staff. It is essential that a communication process be established between the nursing home and the hospice to be used 24-hours a day and that it include how the communication will be documented to reflect concerns and responses. (Refer to F849 - which requires that the written agreement specify the process for hospice and nursing home communication of necessary information regarding the resident’s care.)

Review of Facility Practices/Written Agreement for Hospice Services Any concerns identified by the survey team related to end of life and/or care provided by a hospice should trigger a review of the facility’s policies and procedures on end of life and hospice care and/or related policies (e.g., advance directives). In addition, the survey team should request a copy of the written agreement between the nursing home and the hospice. If there is a failure to develop and or implement portions of the written agreement with a hospice, refer to F849 - Hospice Services.

NOTE: Surveyors should refer the following concerns, as a complaint, to the State agency responsible for oversight of hospice for residents receiving Medicare-certified hospice services;

• Hospice failure to address and resolve concerns made known to them by the nursingfacility which are related to coordination of care or implementation of appropriateservices; and/or

• Hospice failure to provide services in accordance with the coordinated plan of careregardless of notice from the facility.

In addition, if the hospice was advised of the concerns, and failed to resolve issuesrelated to the management of a resident’s care, coordination of care, or implementationof appropriate services, review the nursing home/hospice written agreement todetermine whether there is a failure by the nursing home related to the implementationof the agreement at F849.

The survey team must refer the complaint to the State agency responsible for oversight of hospice, identifying the specific resident(s) involved and the concerns identified. If the hospice was advised of the concerns, and failed to resolve issues related to the management of a resident’s care, coordination of care, or implementation of appropriate services, review the appropriate portions of F849 regarding the written agreement and determine whether there is a failure by the nursing home related to the implementation of the agreement.

INVESTIGATIVE PROTOCOL for F684 – Quality of Care Use Use the General Critical Element (CE) Pathway, or if applicable, the Hospice and End of Life Care and Services CE Pathway, along with the above interpretive guidelines, or applicable professional standards of practice for investigating concerns related to the facility’s requirement to provide treatment and care in accordance with professional standards of practice, the

comprehensive person-centered care plan, and the residents’ choices – for which there is no other Quality of Care tag that would address the issue.

Summary of Investigative Procedure Briefly review the most recent comprehensive assessments, comprehensive care plan and orders to identify whether the facility has recognized and assessed concerns or resident care needs under investigation. If the resident has been in the facility for less than 14 days (before completion of all the Resident Assessment Instrument (RAI) is required), review the baseline care plan which must be completed within 48 hours to determine if the facility is providing appropriate care and services based on information available at the time of admission.

This information will guide observations and interviews to be made in order to corroborate concerns identified. Make note of whether the comprehensive care plan is evaluated and revised based on the resident’s response to interventions. Always observe for visual cues of psychosocial distress and harm (see Appendix P, Guidance on Severity and Scope Levels and Psychosocial Outcome Severity Guide).

During the investigation, identify the extent to which the facility has developed and implemented interventions in accordance with the resident’s needs, goals for care and professional standards of practice for the specific condition or concern being investigated. In any instance in which the surveyor has identified a lack of improvement or a decline, it must be determined whether this was unavoidable or avoidable. In order to make a determination of unavoidable decline or failure to reach highest practicable well-being, the facility must have:

• Conducted an accurate and comprehensive assessment (see §483.20 ResidentAssessment) including evaluating the resident’s clinical condition and risk factors for theconcern being investigated;

• Based on information gathered through resident assessments, withresident/representative input, developed a person centered care plan, defined andimplemented interventions that are consistent with resident needs, goals, and recognizedstandards of practice;

• Implemented the care plan, and monitored resident responses to the interventions; and• Provided ongoing review and revision of the care plan and interventions as necessary.

If the facility has not done one or more of the above bulleted items, and a decline or failure to reach his/her highest practicable well-being occurred, this would be considered an avoidable decline.

NOTE: During the investigation of services provided to a resident from a Medicare-certified hospice determine whether:

• The hospice was advised of concerns by the nursing home and failed to address andresolve issues related to coordination of care or implementation of appropriate services;and/or

• The hospice failed to provide services in accordance with the coordinated care plan,regardless of notice from the facility.

The survey team must refer the above concerns as complaints to the State agency responsible for oversight of hospice, identifying the specific resident(s) involved and the concerns identified. If the hospice was advised of the concerns, and failed to resolve issues related to the management of a resident’s care, coordination of care, or implementation of appropriate services, review the appropriate portions of F849 regarding the written agreement and determine whether there is a failure by the nursing home related to the implementation of the agreement.

KEY ELEMENTS OF NONCOMPLIANCE To cite deficient practice at F684, the surveyor's investigation will generally show that the facility failed to do any one of the following:

• Provide needed care or services resulting in an actual or potential decline in one or more residents’ physical, mental, and/or psychosocial well-being;

• Provide needed care or services (i.e., manage symptoms) resulting in one or more residents’ failure to improve and/or attain their highest practicable physical, mental, and/or psychosocial well-being;

• Recognize and/or assess risk factors placing the resident at risk for specific conditions and/or problems;

• Implement resident-directed care and treatment consistent with the resident’s comprehensive assessment and care plan, preferences, choices, rights, advance directives (if any, and if applicable, according to State law), goals, physician orders, and professional standards of practice, causing a negative outcome, or placing the resident at risk for specific conditions and/or problems.;

• Monitor, evaluate the resident’s response to interventions, and/or revise the interventions as appropriate, causing a negative outcome, or placing the resident at risk for specific conditions and/or problems; and

• Inform and educate the resident who decides to decline care about risks/benefits of such declination; and offer alternative care options and take steps to minimize further decline, causing a negative outcome, or placing the resident at risk for specific conditions and/or problems.

NOTE: Most noncompliance related to the failure to provide care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being can also be cited at other regulations (e.g., assessment, care planning, accommodation of needs, and physician supervision). Surveyors should evaluate compliance with these regulations and cite deficiencies at F684 only when other regulations do not address the deficient practice. Refer to F697 for pain management, and if there is a failure to develop and or implement portions of the written agreement with a hospice, refer to F849 - Hospice Services. DEFICIENCY CATEGORIZATION In addition to actual or potential physical harm, always consider whether psychosocial harm has occurred when determining severity level (See Appendix P, Section IV, E, Psychosocial Outcome Severity Guide). Examples of Severity Level 4 Noncompliance Immediate Jeopardy to Resident Health or Safety include but are not limited to:

• The facility failed to promptly identify and intervene for an acute change in a resident’s condition related to congestive heart failure (CHF), resulting in the family calling 911 to transport the resident to the hospital. The resident was admitted to the hospital with respiratory distress, pulmonary edema, and complications of CHF.(Also cross-referenced and cited at F580, Notification of Changes.)

• As a result of the facility’s continuous or repeated failure to implement comfort measures in accordance with the care plan, the resident experienced serious harm related to uncontrolled vomiting and nausea.

Examples of Severity Level 3 Noncompliance Actual Harm that is Not Immediate Jeopardy include, but are not limited to:

• The facility failed to provide care for a resident with a stasis ulcer as identified on the resident’s care plan and physician’s orders, resulting in worsening of the stasis ulcer, as evidenced by a large area of the skin surrounding the ulcer being reddened, swollen and, according to the nurse, warm to touch. There was exudate and slough on the wound bed, and according to measurements, the wound had increased in size.

• The facility failed to implement a resident’s hospice/nursing home coordinated care plan that specified the resident not being transferred to the hospital for treatment. The facility transferred the resident to the hospital for treatment related to a urinary tract infection even though the resident and the coordinated care plan indicated the resident did not wish to be hospitalized and preferred treatment at the facility. The facility did not contact the hospice prior to initiating the transfer to the hospital. The resident experienced increased pain during the transfer to the hospital and continued to express emotional distress (tearful/crying) over the transfer.

• The resident had requested and the care plan included a symptom management plan with the use of medication to reduce the resident’s symptoms but not to the point that the resident was symptom free so that the resident could be alert and able to participate in visits with family/friends. However, the facility failed to administer the medications as indicated in the plan of care. The resident experienced lethargy and somnolence and was unable to converse/relate to family/friends during visits.

Examples of Severity Level 2 Noncompliance: No Actual Harm, with Potential for More than Minimal Harm, that is Not Immediate Jeopardy include, but are not limited to: Failure to follow physician orders to obtain daily weights for a resident with a diagnosis of congestive heart failure, as evidenced by no documented daily weights on three consecutive weekends. Although this noncompliance resulted in no actual harm to the resident, it has a potential for more than minimal harm if the practice is not corrected. The resident receiving the hospice benefit was on a pain management program utilizing opioids. The resident was experiencing episodic minimal discomfort related to the facility’s failure to consistently implement the bowel management plan as identified in the coordinated care plan. Severity Level 1 Noncompliance: No Actual Harm, with Potential for Minimal Harm Failure to provide appropriate care and services to meet the resident’s physical, mental and/or psychosocial needs places the resident at risk for more than minimal harm. Therefore, Severity Level 1 does not apply for this regulatory requirement.

Summary of Vision and Hearing Investigative Procedure Briefly review the most recent comprehensive assessments, comprehensive care plan, and physician orders to determine if the facility assists residents in gaining access to vision and hearing services by making appointments, and arranging for transportation. Observations, interviews, and record reviews should be utilized to corroborate concerns identified. If the resident has been in the facility for less than 14 days (before completion of all the Resident Assessment Instrument (RAI) is required), review the baseline care plan which must be completed within 48 hours to determine if the facility is providing appropriate care and services based on information available at the time of admission.

F686 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§483.25(b) Skin Integrity§483.25(b)(1) Pressure ulcers.Based on the comprehensive assessment of a resident, the facility must ensure that—

(i) A resident receives care, consistent with professional standards of practice, to preventpressure ulcers and does not develop pressure ulcers unless the individual’s clinicalcondition demonstrates that they were unavoidable; and

(ii) A resident with pressure ulcers receives necessary treatment and services, consistentwith professional standards of practice, to promote healing, prevent infection andprevent new ulcers from developing.

INTENT The intent of this requirement is that the resident does not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to:

• Promote the prevention of pressure ulcer/injury development;• Promote the healing of existing pressure ulcers/injuries (including prevention of infection

to the extent possible); and• Prevent development of additional pressure ulcer/injury.

NOTE: CMS is aware of the array of terms used to describe alterations in skin integrity due to pressure. Some of these terms include: pressure ulcer, pressure injury, pressure sore, decubitus ulcer and bed sore. Clinicians may use and the medical record may reflect any of these terms, as long as the primary cause of the skin alteration is related to pressure. For example, the medical record could reflect the presence of a Stage 2 pressure injury, while the same area would be coded as a Stage 2 pressure ulcer on the MDS.

CMS often refers to the National Pressure Ulcer Advisory Panel’s (NPUAP) terms and definitions, which it has adapted, within its patient and resident assessment instruments and corresponding assessment manuals, which includes the Minimum Data Set (MDS). We intend to continue our adaptation of NPUAP terminology for coding the resident assessment instrument while retaining current holistic assessment instructions definitions and terminology. The adapted terminology was used in the development of this guidance.

Additional information can be found on the NPUAP website at https://www.npuap.org/resources/educational-and-clinical-resources.

NOTE: References to non-CMS/HHS sources or sites on the Internet included above or later in this document are provided as a service and do not constitute or imply endorsement of these organizations or their programs by CMS or the U.S. Department of Health and Human Services. CMS is not responsible for the content of pages found at these sites. URL addresses were current at the date of this publication.

DEFINITIONS Definitions are provided to clarify clinical terms related to pressure injuries and their evaluation and treatment.

“Pressure Ulcer/Injury (PU/PI)” refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue.

Avoidable/Unavoidable • “Avoidable” means that the resident developed a pressure ulcer/injury and that the

facility did not do one or more of the following: evaluate the resident’s clinical conditionand risk factors; define and implement interventions that are consistent with residentneeds, resident goals, and professional standards of practice; monitor and evaluate theimpact of the interventions; or revise the interventions as appropriate.

• “Unavoidable” means that the resident developed a pressure ulcer/injury even thoughthe facility had evaluated the resident’s clinical condition and risk factors; defined andimplemented interventions that are consistent with resident needs, goals, andprofessional standards of practice; monitored and evaluated the impact of theinterventions; and revised the approaches as appropriate.

Colonized/Infected • “Colonized” refers to the presence of micro-organisms on the surface or in the tissue of

a wound without the signs and symptoms of an infection.• “Infected” refers to the presence of micro-organisms in sufficient quantity to overwhelm

the defenses of viable tissues and produce the signs and symptoms of infection.

Debridement- Debridement is the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process. Debridement methods may include a range of treatments such as the use of enzymatic dressings to surgical debridement in order to remove tissue or matter from a wound to promote healing.

Eschar/Slough

• “Eschar” is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound.

• “Slough” is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed.

Exudate

• “Exudate” is any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury. It may contain serum, cellular debris, bacteria and leukocytes.

• “Purulent exudate/drainage/discharge” is any product of inflammation that contains pus (e.g., leukocytes, bacteria, and liquefied necrotic debris).

• “Serous drainage or exudate” is watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage.

Friction/Shearing

• “Friction” is the mechanical force exerted on skin that is dragged across any surface. • “Shearing” occurs when layers of skin rub against each other or when the skin remains

stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage.

Granulation Tissue - “Granulation tissue” is the pink-red moist tissue that fills an open wound, when it starts to heal. It contains new blood vessels, collagen, fibroblasts, and inflammatory cells.

Tunnel/Sinus Tract/Undermining - The terms tunnel and sinus tract are often used interchangeably.

• A “tunnel” is a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound.

• A “sinus tract” is a cavity or channel underlying a wound that involves an area larger than the visible surface of the wound.

• “Undermining” is the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface. Undermining often develops from shearing forces and is differentiated from tunneling by the larger extent of the wound edge involved and the absence of a channel or tract extending from the pressure ulcer under the adjacent intact skin.

GUIDANCE STAGING Staging of a PU/PI is performed to indicate the characteristics and extent of tissue injury, and should be conducted according to professional standards of practice. NOTE: Regardless of the staging system or wound definitions used by the facility, the facility is responsible for completing the MDS utilizing the staging guidelines found in the RAI Manual.

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below). Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident’s physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Other staging considerations include:

• Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent

tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

• Medical Device Related Pressure Ulcer/Injury: Medical device related PU/PIs resultfrom the use of devices designed and applied for diagnostic or therapeutic purposes. Theresultant pressure injury generally conforms to the pattern or shape of the device. Theinjury should be staged using the staging system.

• Mucosal Membrane Pressure Ulcer/Injury: Mucosal membrane PU/PIs are found onmucous membranes with a history of a medical device in use at the location of the injury.Due to the anatomy of the tissue, these ulcers cannot be staged.

PREVENTION OF PRESSURE ULCERS/NJURIES A pressure ulcer/injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must:

• Identify whether the resident is at risk for developing or has a PU/PI upon admission andthereafter;

• Evaluate resident specific risk factors and changes in the resident’s condition that mayimpact the development and/or healing of a PU/PI;

• Implement, monitor and modify interventions to attempt to stabilize, reduce or removeunderlying risk factors; and

• If a PU/PI is present, provide treatment to heal it and prevent the development ofadditional PU/PIs.

The first step in the prevention of PU/PIs, is the identification of the resident at risk of developing PU/PIs. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions.

ASSESSMENT An admission evaluation helps identify residents at risk of developing a PU/PI, and residents with existing PU/PIs. Because a resident at risk can develop a PU/PI within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI. The admission evaluation helps define those initial care approaches.

In addition, the admission evaluation may identify pre-existing signs suggesting that tissue damage has already occurred and additional tissue loss may occur. For example, a deep tissue pressure injury identified on admission could lead to the appearance of an unavoidable Stage 3 or 4 pressure ulcer. A Stage 1 PI can progress to an ulcer with eschar or exudate within days after admission. Some situations, which may have contributed to this tissue damage prior to admission, include pressure resulting from immobility during hospitalization or surgical

procedures, during prolonged ambulance transport, or while waiting to be assisted after a debilitating event, such as a fall or a cerebral vascular accident. It may be harder to identify erythema in a resident with darkly pigmented skin, putting those residents more at risk for developing PU/PIs. It may be necessary, in darker skinned residents to focus more on other evidence of PU/PI development such as changes in sensation, skin temperature or firmness. Multiple factors, including pressure intensity, pressure duration, and tissue tolerance, significantly affect the potential for the development and healing of PUs/PIs. The comprehensive assessment, which includes the RAI, evaluates the resident’s intrinsic risks, the resident’s skin condition, and other factors (including causal factors) which place the resident at risk for the development of or hinder the healing of PU/PIs. An individual may also have various intrinsic risks due to aging, such as decreased subcutaneous tissue and lean muscle mass, decreased skin elasticity, and impaired circulation or sensation. The comprehensive assessment should address those factors that have been identified as having an impact on the development, treatment and/or healing of PU/PIs, including, at a minimum: risk factors, pressure points, under-nutrition and hydration deficits, and moisture and the impact of moisture on skin. The assessment also helps identify the resident who has multi-system organ failure or an end-of-life condition or who is refusing care and treatment. If the resident is refusing care, an evaluation of the basis for the refusal, and the identification and evaluation of potential alternatives is indicated. Risk Factors Not all risk factors are fully modifiable or can be completely addressed. Some risk factors, such as a permanent lack of sensation to an area, may not be modifiable. Some potentially modifiable risk factors, such as malnutrition or uncontrolled blood sugars, may take time to correct, despite prompt intervention. Other risk factors, such as pressure, can be modified promptly. Many studies and professional literature identify risk factors that increase a resident’s susceptibility to develop or to not heal pressure PU/PIs. Examples of these risk factors include, but are not limited to:

• Impaired/decreased mobility and decreased functional ability; • Co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes

mellitus; • Drugs such as steroids that may affect healing; • Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or

lower extremity arterial insufficiency; • Resident refusal of some aspects of care and treatment; • Cognitive impairment; • Exposure of skin to urinary and fecal incontinence; • Under nutrition, malnutrition, and hydration deficits; and • The presence of a previously healed PU/PI. The history of any healed PU/PI, its origin,

treatment, its stages [if known] is important assessment information, since areas of healed Stage 3 or 4 PU/PIs are more likely to have recurrent breakdown.

Although the requirements do not mandate the use of any specific assessment tool (other than the RAI), many validated instruments are available to aid in assessing the risk for developing PU/PIs. It is important to keep in mind that research has shown that in a skilled nursing facility, 80 percent of PU/PIs develop within two weeks of admission and 96 percent develop within three weeks of admission. (Reference: Lyder CH, Ayello EA. Pressure Ulcers: A Patient Safety Issue. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 12. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2650/) Many clinicians utilize a standardized pressure ulcer/injury risk assessment tool to assess a resident’s PU/PI risks upon admission, weekly for the first four weeks after admission, then monthly or whenever there is a change in the resident’s condition. A resident’s risk may increase due to an acute illness or condition change (e.g., upper respiratory infection, pneumonia, or exacerbation of underlying congestive heart failure) and may require additional evaluation. The frequency of assessment should be based upon each resident’s specific needs.

Regardless of any resident’s total risk score on an assessment tool, clinicians are responsible for evaluating each existing and potential risk factor for developing a pressure injury and determining the resident’s overall risk. It is acceptable if the clinician’s assessment places the resident at a higher risk level than the overall score of the assessment tool based on assessment factors that are not captured by the tool. Documentation of the clinician’s decision should be placed in the medical record. Pressure Points and Tissue Tolerance Assessment of a resident’s skin condition helps define prevention strategies. The skin assessment should include an evaluation of the skin integrity. Tissue closest to the bone may be the first tissue to undergo changes related to pressure. PU/PIs are usually located over a bony prominence, such as the sacrum, heel, the greater trochanter, ischial tuberosity, fibular head, scapula, and ankle (malleolus). An at-risk resident who sits too long in one position may be more prone to developing an ulcer/injury over the ischial tuberosity. Slouching in a chair may predispose an at-risk resident to pressure ulcers/injuries of the spine, scapula, or elbow. Elbow pressure injury is often related to arm rests or lap boards. Friction and shearing are also important factors in tissue ischemia, necrosis and PU/PI formation. PU/PIs may develop at other sites where pressure has impaired the circulation to the tissue, such as pressure from positioning or use of medical devices applied for diagnostic or therapeutic purposes. The resultant PU/PI generally conforms to the pattern or shape of the device. Mucosal membrane PU/PIs are found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of mucous membranes, these ulcers cannot be staged.

PU/PIs on the sacrum and heels are most common. PU/PIs may also develop from pressure on an ear lobe related to positioning of the head; on areas (for example, nares, urinary meatus, extremities) caused by tubes, casts, orthotics, braces, cervical collars, or other medical devices; pressure on the labia or scrotum related to positioning (for example, against a pommel type cushion); the foot related to ill-fitting shoes causing blistering; or on legs, arms and fingers due to contractures or deformity.

Nutrition and Hydration Adequate nutrition and hydration are essential for overall functioning. Nutrition provides vital energy and building blocks for all of the body’s structures and processes. Any organ or body system may require additional energy or structural materials for repair or function. The skin is the body’s largest organ system. It may affect, and be affected by, other body processes and organs. Skin condition reflects overall body function therefore, the presence of skin breakdown may be the most visible evidence of a health issue.

Weight reflects a balance between intake and utilization of energy. Significant unintended weight loss may indicate under-nutrition or worsening health status. Weight stability (in the absence of fluid excess or loss) is a useful indicator of overall caloric balance. Severely impaired organs (heart, lungs, kidneys, liver, etc.) may be unable to use nutrients effectively. A resident with a PU/PI who continues to lose weight either needs additional caloric intake or correction (where possible) of conditions that are creating a hypermetabolic state. Continuing weight loss and failure of a PU/PI to heal despite reasonable efforts to improve caloric and nutrient intake may indicate the resident is in multi-system failure or an end-stage or end-of-life condition warranting an additional assessment of the resident’s overall condition.

Before instituting a nutritional care plan, it helps to summarize resident specific evidence, including: severity of nutritional compromise, rate of weight loss or appetite decline, probable causes, the individual’s prognosis and projected clinical course, and the resident’s wishes and goals. Because there are no wound-specific nutritional measures, the interdisciplinary team should develop nutritional goals for the whole person and address nutritional status and needs in the care plan as appropriate.

NOTE: Although some laboratory tests may help clinicians evaluate nutritional issues in a resident with PU/PIs, no laboratory test is specific or sensitive enough to warrant serial/repeated testing. A practitioner may order test(s) that provide useful additional information or help with management of treatable conditions at their discretion

Water is essential to maintain adequate body functions. As a major component of blood, water dissolves vitamins, minerals, glucose, amino acids, etc.; transports nutrients into cells; removes waste from the cells; and helps maintain circulating blood volume as well as fluid and electrolyte balance. It is critical that each resident at risk for hydration deficit or imbalance, including the resident who has or is at risk of developing a PU/PI, be identified and assessed to determine appropriate interventions.

NOTE: The surveyor should refer to the Guidance at 42 CFR 483.25(g), F692, Assisted Nutrition and Hydration, for investigation of potential non-compliance with the nutrition and hydration requirements. A low albumin level combined with the facility’s lack of supplementation, for example, is not by itself sufficient to cite a nutrition related deficiency.

Moisture Both urine and feces contain substances that may irritate the epidermis and may make the skin more susceptible to breakdown and moisture-related skin damage. Fecal incontinence may pose a greater threat to skin integrity, due to bile acids and enzymes in the feces. Irritation or maceration resulting from prolonged exposure to urine and feces may hasten skin breakdown, and moisture may make skin more susceptible to damage from friction and shear during repositioning.

It may be difficult to differentiate dermatitis related to incontinence from partial thickness PU/PI. This differentiation should be based on the clinical evidence and review of presenting risk factors. The dermatitis may occur in the area where the incontinence brief or underpad has been used.

Prevention and Treatment Strategies The comprehensive assessment should provide the basis for defining approaches to address residents at risk of developing or already having a PU/PI. A determination that a resident is at risk for developing a PU/PI has significant implications for preventive and treatment strategies, but does not by itself indicate that development of a PU/PI was unavoidable. Effective prevention and treatment are based upon consistently providing routine and individualized interventions.

Based upon the assessment and the resident’s clinical condition, choices and identified needs, basic or routine care could include, but is not limited to, interventions to:

• Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.);• Minimize exposure to moisture and keep skin clean, especially of fecal contamination;• Provide appropriate, pressure-redistributing, support surfaces;• Provide non-irritating surfaces; and• Maintain or improve nutrition and hydration status, where feasible. Adverse drug

reactions related to the resident's drug regimen may worsen risk factors for developmentof, or for non-healing PU/PIs (for example, by causing lethargy or anorexia orcreating/increasing confusion) and should be identified and addressed. Theseinterventions should be incorporated into the plan of care and revised as the condition ofthe resident indicates.

Resident Choices In the context of the resident’s choices, clinical condition, and physician input, the resident’s care plan should establish relevant goals and approaches to stabilize or improve co-morbidities, such as attempts to minimize clinically significant blood sugar fluctuations, and other interventions aimed at limiting the effects of risk factors associated with PU/PIs. Alternatively, facility staff and practitioners should document clinically valid reasons why such interventions were not appropriate or feasible.

In order for a resident to exercise his or her right appropriately to make informed choices about care and treatment or to decline treatment, the facility and the resident (or if applicable, the resident representative) must discuss the resident’s condition, treatment options, expected outcomes, and consequences of refusing treatment. The facility is expected to address the resident’s concerns and offer relevant alternatives, if the resident has declined specific treatments. (See §483.10(c), F552, Planning and implementing care.)

Pressure Injuries at End of Life Residents at the end of life, in terminal stages of an illness or having multiple system failures may have written directions for his or her treatment goals (or a decision has been made by the resident’s representative, in accordance with State law). The facility’s care must reflect the resident’s goals for care and wishes as expressed in a valid Advance Directive, if one was formulated, in accordance with State law. However, the presence of an Advance Directive does not absolve the facility from giving supportive and other pertinent care that is not prohibited by the resident’s Advance Directive. It is important for surveyors to understand that when a facility has implemented individualized approaches for end-of-life care in accordance with the resident’s wishes, the development, continuation, or worsening of a PU/PI may be considered unavoidable. If the facility has implemented appropriate efforts to stabilize the resident’s condition (or indicted why the condition cannot or should not be stabilized) and has provided care to prevent or treat existing PU/PIs (including pertinent, routine, lesser aggressive approaches, such as, cleaning, turning, repositioning), the PU/PI may be considered unavoidable and consistent with regulatory requirements.

The Kennedy Terminal Ulcer (KTU) The facility is responsible for accurately assessing and classifying an ulcer as a KTU or other type of PU/PI and demonstrate that appropriate preventative measures were in place to prevent non-KTU pressure ulcers.

KTUs have certain characteristics which differentiate them from pressure ulcers such as the following:

• KTUs appear suddenly and within hours;• Usually appear on the sacrum and coccyx but can appear on the heels, posterior calf

muscles, arms and elbows;• Edges are usually irregular and are red, yellow, and black as the ulcer progresses, often

described as pear, butterfly or horseshoe shaped; and• Often appear as an abrasion, blister, or darkened area and may develop rapidly to a

Stage 2, Stage 3, or Stage 4 injury.

Repositioning Repositioning or relieving constant pressure is a common, effective intervention for an individual with a PU/PI or who is at risk of developing one. Assessment of a resident’s skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive care plan consistent with the resident’s need and goals. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning, as the resident is unable to make small movements on their own that would help to relieve prolonged pressure to one area. The

care plan for a resident at risk of friction or shearing during repositioning may require the use of lifting devices for repositioning. Positioning the resident on an existing PU/PI should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. Determine repositioning frequency with consideration to the individual’s:

• Level of activity and mobility, • General medical condition, • Overall treatment objectives, • Skin condition, and • Comfort.

The resident’s skin condition and general comfort should be regularly assessed. The efficacy of repositioning must be monitored and revisions to the care plan considered, if the individual is not responding as expected to the repositioning interventions. Facilities should consider the following repositioning issues: 1. The time an individual spends seated in a chair without pressure relief should be limited.

Seated individuals should be repositioned so as to maintain stability and full range of activities. An acceptable seated posture minimizes the pressure and shear exerted on the skin and soft tissues, which may involve using pressure relieving devices/cushions or adjusting the seat tilt, foot rests, elevated leg rests and other support devices to prevent prolonged pressure to areas of the body that may be at particular risk for developing a PU/PI.

2. If able, the resident should be taught to shift his or her weight while sitting in a chair. A resident who can change positions independently may need supportive devices to facilitate position changes. The resident also may need instruction about why repositioning is important and how to do it, encouragement to change positions regularly, and monitoring of frequency of repositioning.

3. Many clinicians recommend a position change “off - loading” hourly for dependent residents who are sitting or who are in a bed or a reclining chair with the head of the bed or back of the chair raised 30 degrees or more. The resident may require more frequent position changes based on an assessment of their skin condition or their comfort. A “microshift,” meaning a small change in the resident’s position for a short period of time, may not be adequate since this approach does not allow sufficient capillary refill and tissue perfusion for a resident at risk of developing PU/PI’s. Ongoing monitoring of the resident’s skin integrity and tissue tolerance is critical to prevent development or deterioration of PU/PI’s.

4. Wheelchairs are often used for transporting residents, but they may severely limit repositioning options and increase the risk of PU/PI development. Therefore, wheelchairs with sling seats may not be optimal for prolonged sitting during activities or meals, etc. However, available modifications to the seating can provide a more stable surface and provide better pressure reduction.

5. The care plan for a resident who is reclining and is 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 upon the resident’s condition and specific needs. Depending on the individualized assessment, more frequent repositioning may be warranted for individuals who are at higher risk for PU/PI

development or who show evidence that repositioning at 2-hour intervals is inadequate. With rare exception (such as when both sacral and ischial PU/PI’s are present) the resident should not be placed directly on the greater trochanter for more than momentary placement. Elevating the head of the bed or the back of a reclining chair to or above a 30 degree angle creates pressure comparable to that exerted while sitting, and requires the same considerations regarding repositioning as those for a dependent resident who is seated.

Support Surfaces and Pressure Redistribution Pressure redistribution refers to the function or ability to distribute a load over a surface or contact area. Redistribution results in shifting pressure from one area to another and requires attention to all affected areas. Pressure redistribution has incorporated the concepts of both pressure reduction and pressure relief.

Appropriate support surfaces or devices should be chosen by matching a device’s potential therapeutic benefit with the resident’s specific situation; such as multiple injuries, limited turning surfaces, ability to maintain position. The effectiveness of pressure redistribution devices (such as gel mattresses, air fluidized mattresses, and low loss air mattresses) is based on their potential to address the individual resident’s risk, the resident’s response to the product, and the characteristics and condition of the product. For example, an overinflated overlay product, or one that “bottoms out” (when the overlay is underinflated or loses inflation creating less than one inch between the resident and support material) is unlikely to effectively reduce the pressure risk. These products are more likely to reduce pressure effectively if they are used in accord with the manufacturer’s instructions. The effectiveness of each product used needs to be evaluated on an ongoing basis. Surveyors should consider the following pressure redistribution issues:

• Static pressure redistribution devices (such as a gel mattress) may be indicated when a resident is at risk for PU/PI development or delayed healing. A specialized pressure redistribution cushion or surface, for example, might be used to extend the time a resident is sitting in a chair; however, the cushion does not eliminate the necessity for periodic repositioning and skin assessment.

• Dynamic pressure reduction surfaces may be helpful when: o The resident cannot assume a variety of positions without bearing weight on a PU/PI; o The resident completely compresses a static device that has retained its original

integrity; or o The PU/PI is not healing as expected, and it is determined that pressure may be

contributing to the delay in healing. • Because the heels and elbows have relatively little surface area, it is difficult to

redistribute pressure on these two surfaces. Therefore, it is important to pay particular attention to reducing the pressure on these areas for the resident at risk in accord with resident’s overall goals and condition. Pillows used to support the entire lower leg may effectively raise the heel from contact with the bed, but use of the pillows needs to take into account the resident’s other conditions. The use of donut-type cushions is not recommended by the clinicians.

• A resident with severe flexion contractures also may require special attention to effectively reduce pressure on bony prominences or prevent breakdown from skin-to-skin contact.

Some products serve mainly to provide comfort and reduce friction and shearing forces, e.g., sheepskin, heel and elbow protectors. Although these products are not effective at redistributing pressure, they (in addition to pillows, foam wedges, or other measures) may be employed to prevent bony prominences from rubbing together or on other surfaces, such as armrests, the bed, or side rails. Monitoring Staff should remain alert to potential changes in the skin condition and should evaluate, report and document changes as soon as identified. For example, a resident’s complaint about pain or burning at a site where there has been pressure or observation during the resident’s bath that there is a change in skin condition should be reported so that the resident may be evaluated further.

After completing a thorough evaluation, the interdisciplinary team should develop a relevant care plan that includes measurable goals for prevention and management of PU/PIs with appropriate interventions. Many clinicians recommend evaluating skin condition (skin color, moisture, temperature, integrity, and turgor) at least weekly, or more often if indicated, such as when the resident is using a medical device that may cause pressure. Defined interventions should be implemented and monitored for effectiveness. Assessment and Treatment of Pressure Ulcers/Injuries It is important that each existing PU/PI be identified, whether present on admission or developed after admission, and that factors that influenced its development, the potential for development of additional PU/PIs or the deterioration of the PU/PIs be recognized, assessed and addressed. Any new PU/PI suggests a need to reevaluate the adequacy of prevention measures in the resident’s care plan. When assessing the PU/PI itself, it is important that documentation addresses:

• The type of injury (pressure-related versus non-pressure-related) because interventions may vary depending on the specific type of injury;

• The PU/PI’s stage; • A description of the PU/PI’s characteristics; • The progress toward healing and identification of potential complications; • If infection is present; • The presence of pain, what was done to address it, and the effectiveness of the

intervention; and • A description of dressings and treatments.

Types of Injuries Three of the more common types of skin injuries are pressure, vascular insufficiency/ischemia (venous stasis and arterial ischemic ulcers) and neuropathic. See §483.25, F684, Quality of Care, for definition and description of injury types other than PU/PIs. At the time of the assessment, clinicians (physicians, advance practice nurses, physician assistants, and certified wound care specialists, etc.) should document the clinical basis (for

example, type of skin injury, location, shape, edges and wound bed, condition of surrounding tissues) for any determination that an injury is not pressure-related, especially if the injury has characteristics consistent with a pressure injury, but is determined not to be one. Pressure Ulcer/Injury Characteristics It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. When a PU/PIis present, daily monitoring, (with accompanying documentation, when a complication or change is identified), should include:

• An evaluation of the PU/PI, if no dressing is present; • An evaluation of the status of the dressing, if present (whether it is intact and whether

drainage, if present, is or is not leaking); • The status of the area surrounding the PU/PI (that can be observed without removing the

dressing); • The presence of possible complications, such as signs of increasing area of ulceration or

soft tissue infection (for example: increased redness or swelling around the wound or increased drainage from the wound); and

• Whether pain, if present, is being adequately controlled.

The amount of observation possible will depend upon the type of dressing that is used, since some dressings are meant to remain in place for several days, according to manufacturers’ guidelines. 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 PU/PI should be documented. At a minimum, documentation should include the date observed and:

• Location and staging; • Size (perpendicular measurements of the greatest extent of length and width of the

PU/PI), depth; and the presence, location and extent of any undermining or tunneling/sinus tract;

• Exudate, if present: type (such as purulent/serous), color, odor and approximate amount; • Pain, if present: nature and frequency (e.g., whether episodic or continuous); • Wound bed: Color and type of tissue/character including evidence of healing (e.g.,

granulation tissue), or necrosis (slough or eschar); and • Description of wound edges and surrounding tissue (e.g., rolled edges, redness,

hardness/induration, maceration) as appropriate. Photographs may be used to support this documentation, if the facility has developed a protocol consistent with professional standards and issues related to resident privacy and dignity are considered and maintained. Healing Pressure Ulcers/Injuries Ongoing evaluation and research have indicated that PU/PIs do not heal in a reverse sequence, that is, the body does not replace the types and layers of tissue (muscle, fat and dermis) that were

lost during development. The healing process varies depending on the stage of the pressure injury. There are different types of clinical documentation to describe the progression of the healing PU/PI. Facilities are required to use the RAI. Directions on describing PU/PIs can be found in the RAI manual – these are intended for coding purposes of the MDS. (NOTE: Information on coding for the MDS is located on the CMS MDS website (http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#TopOfPage) It is important to evaluate and modify interventions for a resident with an existing PU/PI such as the following:

• Residents with PU/PIs on the sacrum/coccyx or ischia should limit sitting to three times a day in periods of 60 minutes or less. Consult a seating specialist to prescribe an appropriate seating surface and/or positioning techniques to avoid or minimize pressure on the PU/PI. While sitting is important for overall health, every effort should be made to avoid or minimize pressure on the PU/PI.

• Residents with an ischial injury should not be seated in a fully erect posture in chair or in bed. Modify sitting time schedules and re-evaluate the seating surface and the individual’s posture if the PI worsens or fails to improve.

If a PU/PI fails to show some evidence of progress toward healing within 2-4 weeks, the area and the resident’s overall clinical condition should be reassessed. Re-evaluation of the treatment plan includes determining whether to continue or modify the current interventions. Results may vary depending on the resident’s overall condition and interventions/treatments used. The complexity of the resident’s condition may limit responsiveness to treatment or tolerance for certain treatment modalities. The clinicians, if deciding to retain the current regimen, should document the rationale for continuing the present treatment to explain why some, or all, of the plan’s interventions remain relevant despite little or no apparent healing. Pressure ulcers/injuries may progress or may be associated with complications, such as infection of the soft tissues around the wound (cellulitis), infection of the bone (osteomyelitis), infection of a joint (septic arthritis), abscess, spread of bacteria into the bloodstream (bacteremia/septicemia), chronic infection, or development of a sinus tract. Sometimes these complications may occur despite apparent improvement in the PU/PI itself. The physician’s involvement is integral whenever significant changes in the nature of the wound or overall resident condition are identified. Infections A PU/PI infection may be acute or chronic. In acute wounds, the classic signs of inflammation (redness, edema, pain, increased exudate, and periwound surface warmth) persist beyond the normal time frame of three to four days. In residents who are immunosuppressed, the signs of inflammation often are diminished or masked because of an ineffective immune response. Often the only observable symptom of infection is a complaint of pain.

All chronic wounds, including PU/PIs, have bacteria. Since bacteria reside in non-viable tissue, debridement of this tissue and wound cleansing are important to reduce bacteria and avoid adverse outcomes such as sepsis. The first sign of infection may be a delay in healing and an increase in exudates. In a chronic wound, the signs of infection may be more subtle. Signs may include the following:

• Increase in amount or change in characteristics of exudate, • Decolorization and friability of granulation tissue, • Undermining, • Abnormal odor, • Epithelial bridging (a bridge of epithelial tissue across a wound bed) at the base of the

wound, or • Sudden pain.

The physician diagnosis of infections present in a PU/PI are based on resident history and clinical findings, such as a wound culture. Pus, slough or necrotic tissue should not be cultured. Findings such as an elevated white blood cell count, bacteremia, sepsis, or fever may signal an infection related to a PU/PI area or a co-existing infection from a different source. The treatment of an infection will depend on the type of infection present. Pain The assessment and treatment of a resident’s pain are integral components of PU/PI prevention and management. Pain that interferes with movement and/or affects mood may contribute to immobility and contribute to the potential for developing or for delayed healing or non-healing of an already existing PU/PI. Refer to §483.25(k), F697, for additional guidance related to Pain Management. Dressings and Treatments Determination of the need for treatment for a PU/PI is based upon the individual practitioner’s clinical judgment, facility protocols, and current professional standards of practice. Product selection should be based upon the relevance of the specific product to the identified PU/PI(s) characteristics, the treatment goals, and the manufacturer's recommendations for use. Current literature does not indicate significant advantages of any single specific product over another, but does confirm that not all products are appropriate for all PU/PIs. Wound characteristics should be assessed throughout the healing process to assure that the treatments and dressings being used are appropriate to the nature of the wound. Evidenced-based practice suggests that PU/PI dressing protocols may use clean technique rather than sterile, but that appropriate sterile technique may be needed for those wounds that recently have been surgically debrided or repaired. Clean technique (also known as non-sterile) involves approved hand hygiene and glove use, maintaining a clean environment by preparing a clean field, using clean instruments, and preventing direct contamination of materials and supplies. Clean technique is considered most appropriate for long-term care; for residents who are not at high risk for infection; and for residents receiving routine dressings for chronic wounds such as venous ulcers, or wounds healing by secondary intention with granulation tissue.

A facility should be able to show that its treatment protocols are based upon current professional standards of practice and are in accord with the facility’s policies and procedures as developed with the medical director’s review and approval. INVESTIGATIVE PROTOCOL Use Use the Pressure Ulcer Critical Element (CE) Pathway, along with the above interpretive guidelines when determining if the facility meets requirements to ensure a resident receives care consistent with professional standards of practice, to prevent pressure ulcers/injuries development, prevent the development of additional pressure ulcers/injuries, and to promote the healing of existing pressure ulcers/injuries. Summary of Skin Integrity Investigative Procedure Briefly review the comprehensive assessments, care plans, and physician orders to identify whether the facility has practices in place to identify if a resident is at risk for a pressure ulcer/injury, evaluate a resident for pressure ulcers/injuries, and intervene to prevent and/or heal pressure ulcers. During this review, identify the extent to which the facility has developed and implemented interventions in accordance with ensuring a resident receives care consistent with professional standards of practice. If the resident has been in the facility for less than 14 days (before completion of all the Resident Assessment Instrument (RAI) is required), review the baseline care plan which must be completed within 48 hours to determine if the facility is providing appropriate care and services based on information available at the time of admission. This information will guide observations and interviews to be made to corroborate concerns identified.

KEY ELEMENTS OF NONCOMPLIANCE To cite deficient practice at F686, the surveyor's investigation will generally show that the facility failed to do one or more of the following:

• Provide preventive care, consistent with professional standards of practice, to residents who may be at risk for development of pressure injuries; or

• Provide treatment, consistent with professional standards of practice, to an existing pressure injury; or

• Ensure that a resident did not develop an avoidable PU/PI. NOTE: To cite F686, it is not necessary to prove that a PU/PI developed. F686 can be cited when it has been determined that the provider failed to implement interventions to prevent the development of a PU/PI for a resident identified at risk.

DEFICIENCY CATEGORIZATION In addition to actual or potential physical harm, always consider whether psychosocial harm has occurred when determining severity level (See Appendix P, Section IV, E, Psychosocial Outcome Severity Guide).

Examples of Severity Level 4 Noncompliance: Immediate Jeopardy to Resident Health or Safety include but are not limited to:

• The facility failed to implement interventions to prevent PU/PI development for a resident who was admitted without PU/PIs, but who had multiple co-morbidities and was totally dependent on staff, placing her at increased risk for PU/PI development; and failed to provide ongoing skin assessments for the same resident. The resident developed a stage 4 pressure ulcer on her heel within three weeks of her admission.

• Development of avoidable Stage IV pressure ulcer(s): As a result of the facility’s non-compliance, permanent tissue damage (whether or not healing occurs) has compromised the resident, increasing the potential for serious complications including osteomyelitits and sepsis.

• Admitted with a Stage IV pressure ulcer(s) that has shown no signs of healing or shows signs of deterioration: As a result of the facility’s non-compliance, a Stage IV pressure ulcer has shown signs of deterioration or a failure to progress towards healing with an increased potential for serious complications including osteomyelitis and sepsis.

• Stage III or IV pressure ulcers with associated soft tissue or systemic infection: As a result of the facility’s failure to assess or treat a resident with an infectious complication of a pressure ulcer. (See discussion in guidelines and definitions that distinguishes colonization from infection.)

• Extensive failure in multiple areas of pressure ulcer care: As a result of the facility’s extensive noncompliance in multiple areas of pressure ulcer care, the resident developed recurrent and/or multiple, avoidable Stage III or Stage IV pressure ulcer(s).

Examples of Severity Level 3 Noncompliance Actual Harm that is not Immediate Jeopardy include but are not limited to:

• The facility failed to provide necessary equipment, interventions, monitoring, and care, for a resident who was identified to be at risk for developing PU/PIs due to the presence of contractures and had no PU/PIs upon admission. The facility’s occupational therapist (OT) assessed the resident and provided a pressure relieving device for use on the resident’s left hand, which was to be in place at all times except when daily hygiene was being provided. The interventions were not recorded on the resident’s care plan. During observation and interviews with staff, the assistive device was unable to be located and was not in use. This resulted in the resident developing a Stage 3 pressure injury.

• The development of avoidable Stage III pressure ulcer(s): As a result of the facility’s non-compliance, Stage III pressure ulcers occurred, which are open wounds in which damage has occurred into the subcutaneous level and may be painful.

• The development of recurrent or multiple avoidable Stage II pressure ulcer(s): As a result of the facility’s non-compliance, the resident developed multiple and/or recurrent avoidable Stage II ulcers.

• Failure to implement the comprehensive care plan for a resident who has a pressure ulcer: As a result of a facility’s failure to implement a portion of an existing plan related to pressure ulcer care, such as failure to provide for pressure redistribution, or inappropriate treatment/dressing changes, a wound increased in size or failed to progress towards healing as anticipated, or the resident experienced untreated pain.

Examples of Severity Level 2 Noncompliance No Actual Harm with Potential for More Than Minimal Harm that is Not Immediate Jeopardy include but are not limited to:

• The facility failed to assure that a resident with a healed Stage 1 /PI in the coccyx area received care to prevent the development of another PU/PI. The resident’s care plan identified the use of a pressure-relieving device while up in the chair and repositioning every 30 minutes. During observations, the pressure relieving device was not present on the seat of the wheelchair but staff did reposition resident every 30 minutes. The device was available, but the staff person interviewed stated that although it was usually on his wheelchair, it had not been placed that day. The resident’s skin was intact and did not indicate the presence of a stage 1 /PI based on observation, but the likelihood existed of a PU/PI developing as a result of not implementing care as identified in the plan of care.

• The facility failed to assess the skin condition of a resident who used continual oxygen for management of a chronic respiratory disease. The resident’s oxygen was provided via nasal cannula and the resident voiced discomfort and irritation with the tubing on his nares. There was a small reddened area where the tubing contacted the nares. The resident had mentioned this to the staff, but was not addressed, and the resident continued to experience discomfort and irritation.

• The development of a single avoidable Stage II pressure ulcer that is receiving appropriate treatment: As a result of the facility’s non-compliance, a resident developed an avoidable Stage II pressure ulcer.

• The development of an avoidable Stage I pressure ulcer: As a result of the facility’s non-compliance, a resident developed an avoidable Stage I pressure ulcer.

• Failure to implement an element of the care plan for a resident who has a pressure ulcer however, there has been no evidence of decline or failure to heal.

• Failure to recognize or address the potential for developing a pressure ulcer: As a result of the facility’s non-compliance, staff failed to identify the risks, develop a plan of care and/or consistently implement a plan that has been developed to prevent pressure ulcers.

Severity Level 1: No Actual Harm with Potential for Minimal Harm The failure of the facility to provide appropriate care and services to prevent pressure ulcers/injuries or heal existing pressure ulcers/injuries is more than minimal harm. Therefore, Severity Level 1 does not apply for this regulatory requirement. POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION During the investigation of F686, the surveyor may have determined at concerns may also be present with related outcome, process and/or structure requirements. The surveyor is cautioned to investigate these related requirements before determining whether non-compliance may be present. Some examples of related requirements that should be considered include §483.20 Resident Assessment, §483.21 Comprehensive Person-Centered Care Planning, §483.24 Quality of Life, §483.30 Physician Services, §483.35 Nursing Services, §483.70 Administration, and §483.75 QAPI. F687 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.25(b)(2) Foot care.

To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must:

(i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident’s medical condition(s) and

(ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments.

INTENT To ensure that the foot care provided is consistent with professional standards of practice and to clarify that foot care includes treatment to prevent complications from conditions such as diabetes, peripheral vascular disease, or immobility. Also includes assisting the resident in making necessary appointments with qualified healthcare providers such as podiatrists and arranging transportation to and from appointments. GUIDANCE Facilities are responsible for providing the necessary treatment and foot care to residents. Treatment also includes preventive care to avoid podiatric complications in residents with diabetes and circulatory disorders who are prone to developing foot problems. Foot care that is provided in the facility, such as toe nail clipping for residents without complicating disease processes, must be provided by staff who have received education and training to provide this service within professional standards of practice. Residents requiring foot care who have complicating disease processes must be referred to qualified professionals as listed below. Facilities are also responsible for providing residents access to qualified professionals who can treat foot disorders, by making necessary appointments and arranging transportation. Examples include podiatrist, Doctor of Medicine, and Doctor of Osteopathy. Foot disorders which may require treatment include, but are not limited to: corns, neuromas, calluses, hallux valgus (bunions), digiti flexus (hammertoe), heel spurs, and nail disorders. The facility is also responsible for assisting residents in making appointments and arranging transportation to obtain needed services. PROBES: For residents selected for review determine the following:

• According to the medical record, does the resident have a diagnosis or condition that poses a risk to foot health (e.g., diabetes, peripheral vascular disease, ingrown toenails)?

• Does the comprehensive care plan adequately address the resident’s risk with appropriate interventions?

• Observe resident’s feet for lack of nail care, presence of calluses, and/or other foot problems.

• Are residents with foot concerns seen either within the facility or community by a qualified foot care specialist? Do residents with mobility concerns have foot care concerns, and did the facility address these concerns?

• Are qualified healthcare providers available to see residents either in the facility or in the community?

• What preventive foot care do staff provide and to what resident population? • Are staff performing foot care to the resident when needed and ordered?

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SECTION M: SKIN CONDITIONS Intent: The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries. This section also notes other skin ulcers, wounds, or lesions, and documents some treatment categories related to skin injury or avoiding injury. It is important to recognize and evaluate each resident’s risk factors and to identify and evaluate all areas at risk of constant pressure. A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program. Be certain to include in the assessment process, a holistic approach. It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound.

CMS is aware of the array of terms used to describe alterations in skin integrity due to pressure. Some of these terms include: pressure ulcer, pressure injury, pressure sore, decubitus ulcer, and bed sore. Acknowledging that clinicians may use and documentation may reflect any of these terms, it is acceptable to code pressure-related skin conditions in Section M if different terminology is recorded in the clinical record, as long as the primary cause of the skin alteration is related to pressure. For example, if the medical record reflects the presence of a Stage 2 pressure injury, it should be coded on the MDS as a Stage 2 pressure ulcer.

M0100: Determination of Pressure Ulcer/Injury Risk

Item Rationale Health-related Quality of Life

• Pressure ulcers/injuries occur when tissue is compressed between a bony prominence andan external surface. In addition to pressure, shear force, and friction are importantcontributors to pressure ulcer/injury development.

• The underlying health of a resident’s soft tissue affects how much pressure, shear force,or friction is needed to damage tissue. Skin and soft tissue changes associated with aging,illness, small blood vessel disease, and malnutrition increase vulnerability to pressureulcers/injuries.

• Additional external factors, such as excess moisture, microclimate, and tissue exposure tourine or feces, can increase risk.Planning for Care

• The care planning process should include efforts to stabilize, reduce, or removeunderlying risk factors; to monitor the impact of the interventions; and to modify theinterventions as appropriate based on the individualized needs of the resident.

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M0100: Determination of Pressure Ulcer/Injury Risk (cont.) • Throughout this section, terminology referring to

“healed” versus “unhealed” ulcers refers to whether or not the ulcer is “closed” versus “open.” When considering this, recognize that Stage 1, Deep Tissue Injury (DTI), and unstageable pressure ulcers although “closed” (i.e., may be covered with tissue, eschar, slough, etc.) would not be considered “healed.”

• Facilities should be aware that the resident is at higher risk of having the area of a closed pressure ulcer open up due to damage, injury, or pressure, because of the loss of tensile strength of the overlying tissue. Tensile strength of the skin overlying a closed pressure ulcer is 80% of normal skin tensile strength. Facilities should put preventative measures in place that will mitigate the opening of a closed ulcer due to the fragility of the overlying tissue.

Steps for Assessment 1. Review the medical record, including skin care flow sheets

or other skin tracking forms, nurses’ notes, and pressure ulcer/injury risk assessments.

2. Speak with the treatment nurse and direct care staff on all shifts to confirm conclusions from the medical record review and observations of the resident.

3. Examine the resident and determine whether any ulcers, injuries, scars, or non-removable dressings/devices are present. Assess key areas for pressure ulcer/injury development (e.g., sacrum, coccyx, trochanters, ischial tuberosities, and heels). Also assess bony prominences (e.g., elbows and ankles) and skin that is under braces or subjected to pressure (e.g., ears from oxygen tubing).

Coding Instructions For this item, check all that apply:

• Check A if resident has a Stage 1 or greater pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/ device. Review descriptions of pressure ulcers/injuries and information obtained during physical examination and medical record review. Examples of non-removable dressings/devices include a primary surgical dressing, a cast, or a brace.

DEFINITION HEALED PRESSURE ULCER Completely closed, fully epithelialized, covered completely with epithelial tissue, or resurfaced with new skin, even if the area continues to have some surface discoloration.

DEFINITIONS

PRESSURE ULCER/ INJURY RISK FACTOR Examples of risk factors include immobility and decreased functional ability; co-morbid conditions such as end-stage renal disease, thyroid disease, or diabetes; drugs such as steroids; impaired diffuse or localized blood flow; resident refusal of care and treatment; cognitive impairment; exposure of skin to urinary and fecal incontinence; microclimate, malnutrition, and hydration deficits; and a healed ulcer. PRESSURE ULCER/ INJURY RISK TOOLS Screening tools that are designed to help identify residents who might develop a pressure ulcer/injury. A common risk assessment tool is the Braden Scale for Predicting Pressure Sore Risk©.

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M0100: Determination of Pressure Ulcer/Injury Risk (cont.)

• Check B if a formal assessment has been completed. An example of an established pressure ulcer risk tool is the Braden Scale for Predicting Pressure Sore Risk©. Other tools may be used.

• Check C if the resident’s risk for pressure ulcer/injury development is based on clinical assessment. A clinical assessment could include a head-to-toe physical examination of the skin and observation or medical record review of pressure ulcer/injury risk factors. Examples of risk factors include the following:

— impaired/decreased mobility and decreased functional ability — co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes

mellitus; — drugs, such as steroids, that may affect wound healing; — impaired diffuse or localized blood flow (e.g., generalized atherosclerosis or lower

extremity arterial insufficiency); — resident refusal of some aspects of care and treatment; — cognitive impairment; — urinary and fecal incontinence; — malnutrition and hydration deficits; and — healed pressure ulcers, especially Stage 3 or 4 which are more likely to have recurrent

breakdown. • Check Z if none of the above apply.

M0150: Risk of Pressure Ulcers/Injuries

Item Rationale Health-related Quality of Life

• It is important to recognize and evaluate each resident’s risk factors and to identify and evaluate all areas at risk of constant pressure.

Planning for Care • The care process should include efforts to stabilize, reduce, or remove underlying risk

factors; to monitor the impact of the interventions; and to modify the interventions as appropriate.

Steps for Assessment 1. Based on the item(s) reviewed for M0100, determine if the resident is at risk for developing a

pressure ulcer/injury.

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M0150: Risk of Pressure Ulcers/Injuries (cont.) 2. If the medical record reveals that the resident currently has a pressure ulcer/injury, a scar over

a bony prominence, or a non-removable dressing or device, the resident is at risk for worsening or new pressure ulcers/injuries.

3. Review formal risk assessment tools to determine the resident’s “risk score.” 4. Review the components of the clinical assessment conducted for evidence of pressure

ulcer/injury risk.

Coding Instructions • Code 0, no: if the resident is not at risk for developing pressure ulcers/injuries based on

a review of information gathered for M0100.

• Code 1, yes: if the resident is at risk for developing pressure ulcers/injuries based on a review of information gathered for M0100.

M0210: Unhealed Pressure Ulcers/Injuries

Item Rationale Health-related Quality of Life

• Pressure ulcers/injuries and other wounds or lesions affect quality of life for residents because they may limit activity, may be painful, and may require time- consuming treatments and dressing changes. Planning for Care

• The pressure ulcer/injury definitions used in the RAI Manual have been adapted from those recommended by the National Pressure Ulcer Advisory Panel (NPUAP) 2016 Pressure Injury Staging System.

• An existing pressure ulcer/injury identifies residents at risk for further complications or skin injury. Risk factors described in M0100 should be addressed.

• For MDS assessment, initial numerical staging of pressure ulcers and the initial numerical staging of ulcers after debridement, or DTI that declares itself, should be coded in terms of what is assessed (seen or palpated, i.e. visible tissue, palpable bone) during the look-back period. Nursing homes may adopt the NPUAP guidelines in their clinical practice and nursing documentation. However, since CMS has adapted the NPUAP guidelines for MDS purposes, the definitions do not perfectly correlate with each stage as described by NPUAP. Therefore, you must code the MDS according to the instructions in this manual.

DEFINITION PRESSURE ULCER/INJURY A pressure ulcer/injury is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful.

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M0210: Unhealed Pressure Ulcers/Injuries (cont.) • Pressure ulcer/injury staging is an assessment system that provides a description and

classification based on visual appearance and/or anatomic depth of soft tissue damage. This tissue damage can be visible or palpable in the ulcer bed. Pressure ulcer/injury staging also informs expectations for healing times.

• The comprehensive care plan should be reevaluated to ensure that appropriate preventative measures and pressure ulcer/injury management principles are being adhered to when new pressure ulcers/injuries develop or when existing pressure ulcers/injuries worsen.

Steps for Assessment 1. Review the medical record, including skin care flow sheets or other skin tracking forms. 2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical

record review. 3. Examine the resident and determine whether any skin ulcers/injuries are present.

• Key areas for pressure ulcer/injury development include the sacrum, coccyx, trochanters, ischial tuberosities, and heels. Other areas, such as bony deformities, skin under braces, and skin subjected to excess pressure, shear, or friction, are also at risk for pressure ulcers/injuries.

• Without a full body skin assessment, a pressure ulcer/injury can be missed. • Examine the resident in a well-lit room. Adequate lighting is important for detecting skin

changes. For any pressure ulcers/injuries identified, measure and record the deepest anatomical stage.

4. Identify any known or likely unstageable pressure ulcers/injuries.

Coding Instructions Code based on the presence of any pressure ulcer/injury (regardless of stage) in the past 7 days.

• Code 0, no: if the resident did not have a pressure ulcer/injury in the 7-day look-back period. Then skip to M1030, Number of Venous and Arterial Ulcers.

• Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period. Proceed to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.

Coding Tips • If an ulcer/injury arises from a combination of factors that are primarily caused by

pressure, then the area should be included in this section as a pressure ulcer/injury. • Oral Mucosal ulcers caused by pressure should not be coded in Section M. These ulcers

are captured in item L0200C, Abnormal mouth tissue. • Mucosal pressure ulcers are not staged using the skin pressure ulcer staging system

because anatomical tissue comparisons cannot be made. Therefore, mucosal ulcers (for example, those related to nasogastric tubes, nasal oxygen tubing, endotracheal tubes, urinary catheters, etc.) should not be coded here.

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M0210: Unhealed Pressure Ulcers/Injuries (cont.) • If a pressure ulcer is surgically closed with a flap or graft, it should be coded as a surgical

wound and not as a pressure ulcer. If the flap or graft fails, continue to code it as a surgical wound until healed.

• Residents with diabetes mellitus (DM) can have a pressure, venous, arterial, or diabetic neuropathic ulcer. The primary etiology should be considered when coding whether a resident with DM has an ulcer/injury that is caused by pressure or other factors.

• If a resident with DM has a heel ulcer/injury from pressure and the ulcer/injury is present in the 7-day look-back period, code 1 and proceed to code items in M0300 as appropriate for the pressure ulcer/injury.

• If a resident with DM has an ulcer on the plantar (bottom) surface of the foot closer to the metatarsals and the ulcer is present in the 7-day look-back period, code 0 and proceed to M1040 to code the ulcer as a diabetic foot ulcer. It is not likely that pressure is the primary cause of the resident’s ulcer when the ulcer is in this location.

• Scabs and eschar are different both physically and chemically. Eschar is a collection of dead tissue within the wound that is flush with the surface of the wound. A scab is made up of dried blood cells and serum, sits on the top of the skin, and forms over exposed wounds such as wounds with granulating surfaces (like pressure ulcers, lacerations, evulsions, etc.). A scab is evidence of wound healing. A pressure ulcer that was staged as a 2 and now has a scab indicates it is a healing stage 2, and therefore, staging should not change. Eschar characteristics and the level of damage it causes to tissues is what makes it easy to distinguish from a scab. It is extremely important to have staff who are trained in wound assessment and who are able to distinguish scabs from eschar.

• If two pressure ulcers/injuries occur on the same bony prominence and are separated, at least superficially, by skin, then count them as two separate pressure ulcers/injuries. Stage and measure each pressure ulcer/injury separately.

• If a resident had a pressure ulcer/injury that healed during the look-back period of the current assessment, do not code the ulcer/injury on the assessment.

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M0300: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage

Steps for completing M0300A–G

Step 1: Determine Deepest Anatomical Stage For each pressure ulcer, determine the deepest anatomical stage. Do not reverse or back stage. Consider current and historical levels of tissue involvement. 1. Observe and palpate the base of any identified pressure ulcers present to determine the

anatomic depth of soft tissue damage involved. 2. Ulcer staging should be based on the ulcer’s deepest anatomic soft tissue damage that is

visible or palpable. If a pressure ulcer’s tissues are obscured such that the depth of soft tissue damage cannot be observed, it is considered to be unstageable (see Step 2 below). Review the history of each pressure ulcer in the medical record. If the pressure ulcer has ever been classified at a higher numerical stage than what is observed now, it should continue to be classified at the higher numerical stage. Nursing homes that carefully document and track pressure ulcers will be able to more accurately code this item.

3. Pressure ulcers do not heal in a reverse sequence, that is, the body does not replace the types and layers of tissue (e.g., muscle, fat, and dermis) that were lost during pressure ulcer development before they re-epithelialize. Stage 3 and 4 pressure ulcers fill with granulation tissue. This replacement tissue is never as strong as the tissue that was lost and hence is more prone to future breakdown.

4. Clinical standards do not support reverse staging or backstaging as a way to document healing, as it does not accurately characterize what is occurring physiologically as the ulcer heals. For example, over time, even though a Stage 4 pressure ulcer has been healing and contracting such that it is less deep, wide, and long, the tissues that were lost (muscle, fat, dermis) will never be replaced with the same type of tissue. Previous standards using reverse staging or backstaging would have permitted identification of such a pressure ulcer as a Stage 3, then a Stage 2, and so on, when it reached a depth consistent with these stages. Clinical standards now would require that this ulcer continue to be documented as a Stage 4 pressure ulcer until it has completely healed. Nursing homes can document the healing of pressure ulcers using descriptive characteristics of the wound (i.e., depth, width, presence or absence of granulation tissue, etc.) or by using a validated pressure ulcer healing tool. Once a pressure ulcer has healed, it is documented as a healed pressure ulcer at its highest numerical stage—in this example, a healed Stage 4 pressure ulcer. For care planning purposes, this healed Stage 4 pressure ulcer would remain at increased risk for future breakdown or injury and would require continued monitoring and preventative care.

DEFINITIONS EPITHELIAL TISSUE New skin that is light pink and shiny (even in persons with darkly pigmented skin). In Stage 2 pressure ulcers, epithelial tissue is seen in the center and at the edges of the ulcer. In full thickness Stage 3 and 4 pressure ulcers, epithelial tissue advances from the edges of the wound. GRANULATION TISSUE Red tissue with “cobblestone” or bumpy appearance; bleeds easily when injured.

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M0300: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage (cont.)

Step 2: Identify Unstageable Pressure Ulcers 1. Visualization of the wound bed is necessary for accurate staging. 2. If, after careful cleansing of the pressure ulcer/injury, a pressure ulcer’s/injury’s anatomical

tissues remain obscured such that the extent of soft tissue damage cannot be observed or palpated, the pressure ulcer/injury is considered unstageable.

3. Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed, should be classified as unstageable, as illustrated at http://www.npuap.org/wp-content/uploads/2012/03/NPUAP-Unstage2.jpg.

4. If the wound bed is only partially covered by eschar or slough, and the anatomical depth of tissue damage can be visualized or palpated, numerically stage the ulcer, and do not code this as unstageable.

5. A pressure injury with intact skin that is a deep tissue injury (DTI) should not be coded as a Stage 1 pressure injury. It should be coded as unstageable, as illustrated at http://www.npuap.org/wp-content/uploads/2012/03/NPUAP-SuspectDTI.jpg.

6. Known pressure ulcers/injuries covered by a non-removable dressing/device (e.g., primary surgical dressing, cast) should be coded as unstageable. “Known” refers to when documentation is available that says a pressure ulcer/injury exists under the non-removable dressing/device.

Step 3: Determine “Present on Admission” For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. Consider current and historical levels of tissue involvement. 1. Review the medical record for the history of the ulcer/injury. 2. Review for location and stage at the time of admission/entry or reentry. 3. If the pressure ulcer/injury was present on admission/entry or reentry and subsequently

increased in numerical stage during the resident’s stay, the pressure ulcer is coded at that higher stage, and that higher stage should not be considered as “present on admission.”

4. If the pressure ulcer/injury was present on admission/entry or reentry and becomes unstageable due to slough or eschar, during the resident’s stay, the pressure ulcer/injury is coded at M0300F and should not be coded as “present on admission.”

5. If the pressure ulcer/injury was unstageable on admission/entry or reentry, then becomes numerically stageable later, it should be considered as “present on admission” at the stage at which it first becomes numerically stageable. If it subsequently increases in numerical stage, that higher stage should not be coded as “present on admission.”

DEFINITION ON ADMISSION As close to the actual time of admission as possible.

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M0300: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage (cont.) 6. If a resident who has a pressure ulcer/injury that was originally acquired in the facility is

hospitalized and returns with that pressure ulcer/injury at the same numerical stage, the pressure ulcer/injury should not be coded as “present on admission” because it was present and acquired at the facility prior to the hospitalization.

7. If a resident who has a pressure ulcer/injury that was “present on admission” (not acquired in the facility) is hospitalized and returns with that pressure ulcer/injury at the same numerical stage, the pressure ulcer is still coded as “present on admission” because it was originally acquired outside the facility and has not changed in stage.

8. If a resident who has a pressure ulcer/injury is hospitalized and the ulcer/injury increases in numerical stage or becomes unstageable due to slough or eschar during the hospitalization, it should be coded as “present on admission” upon reentry.

9. If a pressure ulcer was numerically staged, then became unstageable, and is subsequently debrided sufficiently to be numerically staged, compare its numerical stage before and after it was unstageable. If the numerical stage has increased, code this pressure ulcer as not present on admission.

10. If two pressure ulcers merge, that were both “present on admission,” continue to code the merged pressure ulcer as “present on admission.” Although two merged pressure ulcers might increase the overall surface area of the ulcer, there needs to be an increase in numerical stage or a change to unstageable due to slough or eschar in order for it to be considered not “present on admission.”

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M0300: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage (cont.)

Examples

1. Ms. K is admitted to the facility without a pressure ulcer/injury. During the stay, she develops a stage 2 pressure ulcer. This is a facility acquired pressure ulcer and was not “present on admission.” Ms. K is hospitalized and returns to the facility with the same stage 2 pressure ulcer. This pressure ulcer was originally acquired in the nursing home and should not be considered as “present on admission” when she returns from the hospital.

2. Mr. J is a new admission to the facility and is admitted with a stage 2 pressure ulcer. This pressure ulcer is considered as “present on admission” as it was not acquired in the facility. Mr. J is hospitalized and returns with the same stage 2 pressure ulcer, unchanged from the prior admission/entry. This pressure ulcer is still considered “present on admission” because it was originally acquired outside the facility and has not changed.

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M0300A: Number of Stage 1 Pressure Injuries

Item Rationale Health-related Quality of Care

• Stage 1 pressure injuries may deteriorate to more severe pressure ulcers/injuries without adequate intervention; as such, they are an important risk factor for further tissue damage.

Planning for Care • Development of a Stage 1 pressure injury should be one

of multiple factors that initiate pressure ulcer/injury prevention interventions.

Steps for Assessment 1. Perform head-to-toe assessment. Conduct a full body skin

assessment focusing on bony prominences and pressure- bearing areas (sacrum, buttocks, heels, ankles, etc.).

2. For the purposes of coding, determine that the lesion being assessed is primarily related to pressure and that other conditions have been ruled out. If pressure is not the primary cause, do not code here.

3. Reliance on only one descriptor is inadequate to determine the staging of a pressure injury between Stage 1 and deep tissue injury (see definition of “deep tissue injury” on page M-24). The descriptors are similar for these two types of injuries (e.g., temperature [warmth or coolness]; tissue consistency [firm or boggy]).

4. Check any reddened areas for ability to blanch by firmly pressing a finger into the reddened tissues and then removing it. In non-blanchable reddened areas, there is no loss of skin color or pressure-induced pallor at the compressed site.

5. Search for other areas of skin that differ from surrounding tissue that may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. Stage 1 may be difficult to detect in individuals with dark skin tones. Visible blanching may not be readily apparent in darker skin tones. Look for temperature or color changes as well as surrounding tissue that may be painful, firm, or soft.

DEFINITIONS STAGE 1 PRESSURE INJURY An observable, pressure- related alteration of intact skin whose indicators, as compared to an adjacent or opposite area on the body, may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the injury may appear with persistent red, blue, or purple hues. NON-BLANCHABLE Reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device.

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M0300A: Number of Stage 1 Pressure Injuries (cont.) Coding Instructions for M0300A

• Enter the number of Stage 1 pressure injuries that are currently present.

• Enter 0 if no Stage 1 pressure injuries are currently present.

M0300B: Stage 2 Pressure Ulcers

Item Rationale Health-related Quality of Life

• Stage 2 pressure ulcers may worsen without proper interventions.

• These residents are at risk for further complications or skin injury.

Planning for Care • Most Stage 2 pressure ulcers should heal in a

reasonable time frame (e.g., 60 days).

• If a pressure ulcer fails to show some evidence toward healing within 14 days, the pressure ulcer (including potential complications) and the patient’s overall clinical condition should be reassessed.

• Stage 2 pressure ulcers are often related to friction and/or shearing force, and the care plan should incorporate efforts to limit these forces on the skin and tissues.

• Stage 2 pressure ulcers may be more likely to heal with treatment than higher stage pressure ulcers.

• The care plan should include individualized interventions and evidence that the interventions have been monitored and modified as appropriate.

DEFINITION STAGE 2 PRESSURE ULCER Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.

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M0300B: Stage 2 Pressure Ulcers (cont.) Steps for Assessment 1. Perform head-to-toe assessment. Conduct a full body skin assessment focusing on bony

prominences and pressure-bearing areas (sacrum, buttocks, heels, ankles, etc.). 2. For the purposes of coding, determine that the lesion being assessed is primarily related to

pressure and that other conditions have been ruled out. If pressure is not the primary cause, do not code here.

3. Examine the area adjacent to or surrounding an intact blister for evidence of tissue damage. If other conditions are ruled out and the tissue adjacent to or surrounding the blister demonstrates signs of tissue damage (e.g., color change, tenderness, bogginess or firmness, warmth or coolness), these characteristics suggest a deep tissue injury (DTI) rather than a Stage 2 pressure ulcer.

4. Stage 2 pressure ulcers will generally lack the surrounding characteristics found with a deep tissue injury.

5. Identify the number of these pressure ulcers that were present on admission/entry or reentry (see instructions on page M-8).

Coding Instructions for M0300B M0300B1

• Enter the number of pressure ulcers that are currently present and whose deepest anatomical stage is Stage 2.

• Enter 0 if no Stage 2 pressure ulcers are present and skip to M0300C, Stage 3.

M0300B2 • Enter the number of these Stage 2 pressure ulcers that were first noted at the time of

admission/entry AND—for residents who are reentering the facility after a hospital stay, enter the number of Stage 2 pressure ulcers that were acquired during the hospitalization (i.e., the Stage 2 pressure ulcer was not acquired in the nursing facility prior to admission to the hospital).

• Enter 0 if no Stage 2 pressure ulcers were first noted at the time of admission/entry or reentry.

Coding Tips • Stage 2 pressure ulcers by definition have partial thickness loss of the dermis.

Granulation tissue, slough, and eschar are not present in Stage 2 pressure ulcers. • Do not code skin tears, tape burns, moisture associated skin damage, or excoriation here.

• When a pressure ulcer presents as an intact blister, examine the adjacent and surrounding area for signs of deep tissue injury. When a deep tissue injury is determined, do not code as a Stage 2.

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M0300C: Stage 3 Pressure Ulcers

Item Rationale Health-related Quality of Life

• Pressure ulcers affect quality of life for residents because they may limit activity, may be painful, and may require time-consuming treatments and dressing changes.

Planning for Care • Pressure ulcers at more advanced stages typically

require more aggressive interventions, including more frequent repositioning, attention to nutritional status, and care that may be more time or staff intensive.

• An existing pressure ulcer may put residents at risk for further complications or skin injury.

• If a pressure ulcer fails to show some evidence toward healing within 14 days, the pressure ulcer (including potential complications) and the resident’s overall clinical condition should be reassessed.

• Tissue characteristics of pressure ulcers should be considered when determining treatment options and choices.

• Changes in tissue characteristics over time are indicative of wound healing or degeneration.

Steps for Assessment 1. Perform head-to-toe assessment. Conduct a full body skin assessment focusing on bony

prominences and pressure-bearing areas (sacrum, buttocks, heels, ankles, etc.). 2. For the purposes of coding, determine that the lesion being assessed is primarily related to

pressure and that other conditions have been ruled out. If pressure is not the primary cause, do not code here.

3. Identify all Stage 3 pressure ulcers currently present. 4. Identify the number of these pressure ulcers that were present on admission/entry or reentry.

DEFINITION STAGE 3 PRESSURE ULCER Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling (see definition of undermining and tunneling on page M-17).

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M0300C: Stage 3 Pressure Ulcers (cont.) Coding Instructions for M0300C

M0300C1 • Enter the number of pressure ulcers that are currently present and whose deepest

anatomical stage is Stage 3.

• Enter 0 if no Stage 3 pressure ulcers are present and skip to M0300D, Stage 4.

M0300C2 • Enter the number of these Stage 3 pressure ulcers that were first noted at Stage 3 at

the time of admission/entry AND—for residents who are reentering the facility after a hospital stay, enter the number of Stage 3 pressure ulcers that were acquired during the hospitalization (i.e., the Stage 3 pressure ulcer was not acquired in the nursing facility prior to admission to the hospital).

• Enter 0 if no Stage 3 pressure ulcers were first noted at the time of admission/entry or reentry.

Coding Tips • The depth of a Stage 3 pressure ulcer varies by anatomical location. Stage 3 pressure

ulcers can be shallow, particularly on areas that do not have subcutaneous tissue, such as the bridge of the nose, ear, occiput, and malleolus.

• In contrast, areas of significant adiposity can develop extremely deep Stage 3 pressure ulcers. Therefore, observation and assessment of skin folds should be part of overall skin assessment. Do not code moisture-associated skin damage or excoriation here.

• Bone/tendon/muscle is not visible or directly palpable in a Stage 3 pressure ulcer.

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M0300C: Stage 3 Pressure Ulcers (cont.) Examples 1. A pressure ulcer described as a Stage 2 was noted and documented in the resident’s medical

record on admission. On a later assessment, the wound is noted to be a full thickness ulcer without exposed bone, tendon, or muscle, thus it is now a Stage 3 pressure ulcer.

Coding: The current Stage 3 pressure ulcer would be coded at M0300C1 as 1, and at M0300C2 as 0, not present on admission/entry or reentry. Rationale: The designation of “present on admission” requires that the pressure ulcer be at the same location and not have increased in numerical stage or become unstageable due to slough or eschar. This pressure ulcer worsened from Stage 2 to Stage 3 after admission. M0300C1 is coded as 1 and M0300C2 is coded as 0 on the current assessment because the ulcer was not a Stage 3 pressure ulcer on admission.

2. A resident develops a Stage 2 pressure ulcer while at the nursing facility. The resident is hospitalized due to pneumonia for 8 days and returns with a Stage 3 pressure ulcer in the same location.

Coding: The pressure ulcer would be coded at M0300C1 as 1, and at M0300C2 as 1, present on admission/entry or reentry. Rationale: Even though the resident had a pressure ulcer in the same anatomical location prior to transfer, because the pressure ulcer increased in numerical stage to Stage 3 during hospitalization, it should be coded as Stage 3, present on admission/entry or reentry.

3. On admission, the resident has three small Stage 2 pressure ulcers on her coccyx. Two weeks later, the coccyx is assessed. Two of the Stage 2 pressure ulcers have merged and the third has increased in numerical stage to a Stage 3 pressure ulcer.

Coding: The two merged pressure ulcers would be coded at M0300B1 as 1, and at M0300B2 as 1, present on admission/entry or reentry. The Stage 3 pressure ulcer would be coded at M0300C1 as 1, and at M0300C2 as 0, not present on admission/entry or reentry. Rationale: Two of the pressure ulcers on the coccyx have merged, but have remained at the same stage as they were at the time of admission; therefore, M0300B1 and M0300B2 would be coded as 1; the pressure ulcer that increased in numerical stage to a Stage 3 is coded in M0300C1 as 1 and in M0300C2 as 0, not present on admission/entry or reentry since the Stage 3 ulcer was not present on admission/entry or reentry and developed a deeper level of tissue damage in the time since admission.

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M0300C: Stage 3 Pressure Ulcers (cont.) 4. A resident developed two Stage 2 pressure ulcers during her stay; one on the coccyx and the

other on the left lateral malleolus. At some point she is hospitalized and returns with two pressure ulcers. One is the previous Stage 2 on the coccyx, which has not changed; the other is a new Stage 3 on the left trochanter. The Stage 2 previously on the left lateral malleolus has healed.

Coding: The Stage 2 pressure ulcer would be coded at M0300B1 as 1, and at M0300B2 as 0, not present on admission/entry or reentry; the Stage 3 pressure ulcer would be coded at M0300C1 as 1, and at M0300C2 as 1, present on admission/entry or reentry. Rationale: The Stage 2 pressure ulcer on the coccyx was present prior to hospitalization; the Stage 3 pressure ulcer developed during hospitalization and is coded in M0300C2 as present on admission/entry or reentry. The Stage 2 pressure ulcer on the left lateral malleolus has healed and is therefore no longer coded here.

5. A resident is admitted to a nursing facility with a short leg cast to the right lower extremity. He has no visible wounds on admission but arrives with documentation that a pressure ulcer exists under the cast. Two weeks after admission to the nursing facility, the cast is removed by the physician. Following the removal of the cast, the right heel is observed and assessed as a Stage 3 pressure ulcer, which remains until the subsequent assessment.

Coding: Code M0300C1 as 1, and M0300C2 as 1, present on admission/entry or reentry. Rationale: The resident was admitted with a documented unstageable pressure ulcer/injury due to non-removable dressing/device. The cast was removed, and a Stage 3 pressure ulcer was assessed. Because this is the first time the ulcer has been numerically staged, this stage will be coded as present on admission/entry or reentry.

6. Mrs. P was admitted to the nursing facility with a blood-filled blister on the right heel. After further assessment of the surrounding tissues, it is determined that the heel blister is a DTI. Three weeks after admission, the right-heel blister is drained and conservatively debrided at the bedside. After debridement, the right heel is staged as a Stage 3 pressure ulcer. On the subsequent assessment, the right heel remains at Stage 3.

Coding: Code M0300C1 as 1, and M0300C2 as 1, present on admission/entry or reentry. Rationale: This resident was admitted with an unstageable DTI that subsequently was debrided and could be numerically staged. The first numerical stage was 3, and it remained a Stage 3 for the subsequent assessment; therefore it is coded as present on admission/entry or reentry.

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M0300C: Stage 3 Pressure Ulcers (cont.) 7. Mr. H was admitted with a known pressure ulcer/injury due to a non-removable dressing.

Ten days after admission, the surgeon removed the dressing, and a Stage 2 pressure ulcer was identified. Two weeks later the pressure ulcer is determined to be a full thickness ulcer and is at that point Stage 3. It remained Stage 3 at the time of the next assessment.

Coding: Code M0300C1 as 1, and M0300C2 as 0, not present on admission/entry reentry. Rationale: This resident was admitted with an unstageable pressure ulcer due to non-removable dressing or device. The dressing was removed to reveal a Stage 2 pressure ulcer, and this is the first numerical stage. Subsequent to this first stage, the ulcer worsened to Stage 3 and therefore is not coded as present on admission/entry or reentry.

M0300D: Stage 4 Pressure Ulcers

Item Rationale Health-related Quality of Life

• Pressure ulcers affect quality of life for residents because they may limit activity, may be painful, and may require time-consuming treatments and dressing changes.

Planning for Care • Pressure ulcers at more advanced stages typically

require more aggressive interventions, including more frequent repositioning, attention to nutritional status, more frequent dressing changes, and treatment that is more time-consuming than with routine preventive care.

• An existing pressure ulcer may put residents at risk for further complications or skin injury.

• If a pressure ulcer fails to show some evidence toward healing within 14 days, the pressure ulcer (including potential complications) and the resident’s overall clinical condition should be reassessed.

DEFINITION STAGE 4 PRESSURE ULCER Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.

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M0300D: Stage 4 Pressure Ulcers (cont.) Steps for Assessment 1. Perform head-to-toe assessment. Conduct a full body skin

assessment focusing on bony prominences and pressure-bearing areas (sacrum, buttocks, heels, ankles, etc.).

2. For the purposes of coding, determine that the lesion being assessed is primarily related to pressure and that other conditions have been ruled out. If pressure is not the primary cause, do not code here.

3. Identify all Stage 4 pressure ulcers currently present. 4. Identify the number of these pressure ulcers that were

present on admission/entry or reentry.

Coding Instructions for M0300D M0300D1

• Enter the number of pressure ulcers that are currently present and whose deepest anatomical stage is Stage 4.

• Enter 0 if no Stage 4 pressure ulcers are present and skip to M0300E, Unstageable – Non-removable dressing. M0300D2

• Enter the number of these Stage 4 pressure ulcers that were first noted at Stage 4 at the time of admission/entry AND—for residents who are reentering the facility after a hospital stay, enter the number of Stage 4 pressure ulcers that were acquired during the hospitalization (i.e., the Stage 4 pressure ulcer was not acquired in the nursing facility prior to admission to the hospital).

• Enter 0 if no Stage 4 pressure ulcers were first noted at the time of admission/entry or reentry.

Coding Tips • The depth of a Stage 4 pressure ulcer varies by anatomical location. The bridge of the

nose, ear, occiput, and malleolus do not have subcutaneous tissue, and these ulcers can be shallow.

• Stage 4 pressure ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis possible.

• Exposed bone/tendon/muscle is visible or directly palpable.

• Cartilage serves the same anatomical function as bone. Therefore, pressure ulcers that have exposed cartilage should be classified as a Stage 4.

DEFINITIONS TUNNELING A passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound. UNDERMINING The destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface.

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M0300D: Stage 4 Pressure Ulcers (cont.) • Assessment of the pressure ulcer for tunneling and undermining is an important part of

the complete pressure ulcer assessment. Measurement of tunneling and undermining is not recorded on the MDS, but should be assessed, monitored, and treated as part of the comprehensive care plan.

M0300E: Unstageable Pressure Ulcers/Injuries Related to Non-removable Dressing/Device

Item Rationale Health-related Quality of Life

• Although the wound bed cannot be visualized, and hence the pressure ulcer/injury cannot be staged, the pressure ulcer/injury may affect quality of life for residents because it may limit activity and may be painful.

Planning for Care • Although the pressure ulcer/injury itself cannot be observed, the surrounding area is

monitored for signs of redness, swelling, increased drainage, or tenderness to touch, and the resident is monitored for adequate pain control.

Steps for Assessment 1. Review the medical record for documentation of a pressure ulcer/injury covered by a non-

removable dressing/device. 2. Determine the number of documented pressure ulcers/injuries covered by a non-removable

dressing/device. Examples of non-removable dressings/devices include a dressing or an orthopedic device that is not to be removed per physician’s order, or a cast.

3. Identify the number of these pressure ulcers/injuries that were present on admission/entry or reentry (see page M-8 for assessment process).

Coding Instructions for M0300E M0300E1

• Enter the number of pressure ulcers/injuries that are unstageable related to non-removable dressing/device.

DEFINITION NON-REMOVABLE DRESSING/ DEVICE Includes, for example, a primary surgical dressing that cannot be removed, an orthopedic device, or cast.

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M0300E: Unstageable Pressure Ulcers/Injuries Related to Non-removable Dressing/Device (cont.)

• Enter 0 if no unstageable pressure ulcers/injuries related to non-removable dressing/device are present and skip to M0300F, Unstageable – Slough and/or eschar.

M0300E2 • Enter the number of these unstageable pressure ulcers/injuries related to a non-

removable dressing/device that were first noted at the time of admission/entry AND—for residents who are reentering the facility after a hospital stay, that were acquired during the hospitalization (i.e., the unstageable pressure ulcer/injury related to a non-removable dressing/device was not acquired in the nursing facility prior to admission to the hospital).

• Enter 0 if no unstageable pressure ulcers/injuries related to non-removable dressing/device were first noted at the time of admission/entry or reentry.

M0300F: Unstageable Pressure Ulcers Related to Slough and/or Eschar

Item Rationale Health-related Quality of Life

• Although the wound bed cannot be visualized, and hence the pressure ulcer cannot be staged, the pressure ulcer may affect quality of life for residents because it may limit activity, may be painful, and may require time-consuming treatments and dressing changes. Planning for Care

• Visualization of the wound bed is necessary for accurate staging.

• The presence of pressure ulcers and other skin changes should be accounted for in the interdisciplinary care plan.

• Pressure ulcers that present as unstageable require care planning that includes, in the absence of ischemia, debridement of necrotic and dead tissue and restaging once this tissue is removed.

DEFINITIONS SLOUGH TISSUE Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. ESCHAR TISSUE Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound.

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M0300F: Unstageable Pressure Ulcers Related to Slough and/or Eschar (cont.) Steps for Assessment 1. Determine the number of pressure ulcers that are unstageable due to slough and/or eschar. 2. Identify the number of these pressure ulcers that were present on admission/entry or reentry

(see page M-8 for assessment process).

Coding Instructions for M0300F M0300F1

• Enter the number of pressure ulcers that are unstageable related to slough and/or eschar.

• Enter 0 if no unstageable pressure ulcers related to slough and/or eschar are present and skip to M0300G, Unstageable – Deep tissue injury.

M0300F2 • Enter the number of these unstageable pressure ulcers related to slough and/or eschar

that were first noted at the time of admission/entry AND—for residents who are reentering the facility after a hospital stay that were acquired during the hospitalization (i.e., the unstageable pressure ulcer related to slough and/or eschar was not acquired in the nursing facility prior to admission to the hospital).

• Enter 0 if no unstageable pressure ulcers related to slough and/or eschar were first noted at the time of admission/entry or reentry.

Coding Tips • Pressure ulcers that are covered with slough and/or

eschar, and the wound bed cannot be visualized, should be coded as unstageable because the true anatomic depth of soft tissue damage (and therefore stage) cannot be determined. Only until enough slough and/or eschar is removed to expose the anatomic depth of soft tissue damage involved, can the stage of the wound be determined.

• Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heels serves as “the body’s natural (biological) cover” and should only be removed after careful clinical consideration, including ruling out ischemia, and consultation with the resident’s physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws.

• Once the pressure ulcer is debrided of slough and/or eschar such that the anatomic depth of soft tissue damage involved can be determined, then code the ulcer for the reclassified stage. The pressure ulcer does not have to be completely debrided or free of all slough and/or eschar tissue in order for reclassification of stage to occur.

DEFINITION FLUCTUANCE Used to describe the texture of wound tissue indicative of underlying unexposed fluid.

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M0300F: Unstageable Pressure Ulcers Related to Slough and/or Eschar (cont.) Examples 1. A resident is admitted with a sacral pressure ulcer that is 100% covered with black eschar.

Coding: The pressure ulcer would be coded at M0300F1 as 1, and at M0300F2 as 1, present on admission/entry or reentry. Rationale: The pressure ulcer depth is not observable because the pressure ulcer is covered with eschar. This pressure ulcer is unstageable and was present on admission.

2. A pressure ulcer on the sacrum was present on admission and was 100% covered with black eschar. On the admission assessment, it was coded as unstageable and present on admission. The pressure ulcer is later debrided using conservative methods and after 4 weeks the ulcer has 50% to 75% eschar present. The assessor can now see that the damage extends down to the bone.

Coding: The ulcer is reclassified as a Stage 4 pressure ulcer. On the subsequent MDS, it is coded at M0300D1 as 1, and at M0300D2 as 1, present on admission/entry or reentry. Rationale: After debridement, the pressure ulcer is no longer unstageable because bone is visible in the wound bed. Therefore, this ulcer can be classified as a Stage 4 pressure ulcer and should be coded at M0300D.

3. Miss J. was admitted with one small Stage 2 pressure ulcer. Despite treatment, it is not improving. In fact, it now appears deeper than originally observed, and the wound bed is covered with slough.

Coding: Code M0300F1 as 1, and M0300F2 as 0, not present on admission/entry or reentry. Rationale: The pressure ulcer depth is not observable because it is covered with slough. This pressure ulcer is unstageable and is not coded in M0300F2 as present on admission/entry or reentry because it can no longer be coded as a Stage 2.

4. Mr. M. was admitted to the nursing facility with eschar tissue covering both the right and left heels, as well as a Stage 2 pressure ulcer on the coccyx. Mr. M’s pressure ulcers were reassessed before the subsequent assessment, and the Stage 2 coccyx pressure ulcer had healed. The left-heel eschar became fluctuant, showed signs of infection, had to be debrided at the bedside, and was subsequently numerically staged as a Stage 4 pressure ulcer. The right-heel eschar remained stable and dry (i.e., remained unstageable).

Coding: Code M0300D1 as 1, and M0300D2 as 1, present on admission/entry or reentry. Code M0300F1 as 1, and M0300F2 as 1, present on admission/entry or reentry. Rationale: Mr. M was admitted with an unstageable pressure injury due to slough/eschar on each heel. One of the heels was subsequently debrided, and the first numerical stage was Stage 4; thus this is coded as present on admission/entry or reentry. The other heel eschar remained unstageable, and is coded as present on admission/entry or reentry.

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M0300G: Unstageable Pressure Injuries Related to Deep Tissue Injury

Item Rationale Health-related Quality of Life

• Deep tissue injury may precede the development of a Stage 3 or 4 pressure ulcer even with optimal treatment.

• Quality health care begins with prevention and risk assessment, and care planning begins with prevention. Appropriate care planning is essential in optimizing a resident’s ability to avoid, as well as recover from, pressure (as well as all) wounds/injuries. Deep tissue injuries may sometimes indicate severe damage. Identification and management of deep tissue injury (DTI) is imperative.

Planning for Care • Deep tissue injury requires vigilant monitoring because of the potential for rapid

deterioration. Such monitoring should be reflected in the care plan.

Steps for Assessment 1. Perform head-to-toe assessment. Conduct a full body skin assessment focusing on bony

prominences and pressure-bearing areas (sacrum, buttocks, heels, ankles, etc.). 2. For the purposes of coding, determine that the lesion being assessed is primarily a result of

pressure and that other conditions have been ruled out. If pressure is not the primary cause, do not code here.

3. Examine the area adjacent to, or surrounding, an intact blister for evidence of tissue damage. If the tissue adjacent to, or surrounding, the blister does not show signs of tissue damage (e.g., color change, tenderness, bogginess or firmness, warmth or coolness), do not code as a deep tissue injury.

4. In dark-skinned individuals, the area of injury is probably not purple/maroon, but rather darker than the surrounding tissue.

5. Determine the number of pressure injuries that are unstageable related to deep tissue injury. 6. Identify the number of these pressure injuries that were present on admission/entry or reentry

(see page M-8 for instructions). 7. Clearly document assessment findings in the resident’s medical record, and track and

document appropriate wound care planning and management.

DEFINITION DEEP TISSUE INJURY Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

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M0300G: Unstageable Pressure Injuries Related to Deep Tissue Injury (cont.) Coding Instructions for M0300G

M0300G1 • Enter the number of unstageable pressure injuries related to deep tissue injury. Based

on skin tone, the injured tissue area may present as a darker tone than the surrounding intact skin. These areas of discoloration are potentially areas of deep tissue injury.

• Enter 0 if no unstageable pressure injuries related to deep tissue injury are present and skip to M1030, Number of Venous and Arterial Ulcers.

M0300G2 • Enter the number of these unstageable pressure injuries related to deep tissue injury

that were first noted at the time of admission/entry AND—for residents who are reentering the facility after a hospital stay, that were acquired during the hospitalization (i.e., the unstageable pressure injury related to deep tissue injury was not acquired in the nursing facility prior to admission to the hospital).

• Enter 0 if no unstageable pressure injuries related to deep tissue injury were first noted at the time of admission/entry or reentry.

Coding Tips • Once deep tissue injury has opened to an ulcer, reclassify the ulcer into the appropriate

stage. Then code the ulcer for the reclassified stage.

• Deep tissue injury may be difficult to detect in individuals with dark skin tones.

• Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

• When a lesion due to pressure presents with an intact blister AND the surrounding or adjacent soft tissue does NOT have the characteristics of deep tissue injury, do not code here (see definition of Stage 2 pressure ulcer on page M-12).

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M1030: Number of Venous and Arterial Ulcers

Item Rationale Health-related Quality of Life

• Skin wounds and lesions affect quality of life for residents because they may limit activity, may be painful, and may require time-consuming treatments and dressing changes.

Planning for Care • The presence of venous and arterial ulcers should be

accounted for in the interdisciplinary care plan.

• This information identifies residents at risk for further complications or skin injury.

Steps for Assessment 1. Review the medical record, including skin care flow sheet

or other skin tracking form. 2. Speak with direct care staff and the treatment nurse to

confirm conclusions from the medical record review. 3. Examine the resident and determine whether any venous or

arterial ulcers are present.

• Key areas for venous ulcer development include the area proximal to the lateral and medial malleolus (e.g., above the inner and outer ankle area).

• Key areas for arterial ulcer development include the distal part of the foot, dorsum or tops of the foot, or tips and tops of the toes.

• Venous ulcers may or may not be painful and are typically shallow with irregular wound edges, a red granular (e.g., bumpy) wound bed, minimal to moderate amounts of yellow fibrinous material, and moderate to large amounts of exudate. The surrounding tissues may be erythematous or reddened, or appear brown-tinged due to hemosiderin staining. Leg edema may also be present.

• Arterial ulcers are often painful and have a pale pink wound bed, necrotic tissue, minimal exudate, and minimal bleeding.

DEFINITIONS VENOUS ULCERS Ulcers caused by peripheral venous disease, which most commonly occur proximal to the medial or lateral malleolus, above the inner or outer ankle, or on the lower calf area of the leg. ARTERIAL ULCERS Ulcers caused by peripheral arterial disease, which commonly occur on the tips and tops of the toes, tops of the foot, or distal to the medial malleolus.

DEFINITION

HEMOSIDERIN An intracellular storage form of iron; the granules consist of an ill-defined complex of ferric hydroxides, polysaccharides, and proteins having an iron content of approximately 33% by weight. It appears as a dark yellow-brown pigment.

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M1030: Number of Venous and Arterial Ulcers (cont.)

Coding Instructions Check all that apply in the last 7 days. Pressure ulcers coded in M0210 through M0300 should not be coded here.

• Enter the number of venous and arterial ulcers present.

• Enter 0: if there were no venous or arterial ulcers present.

Coding Tips Arterial Ulcers

• Trophic skin changes (e.g., dry skin, loss of hair growth, muscle atrophy, brittle nails) may also be present. The wound may start with some kind of minor trauma, such as hitting the leg on a wheelchair. The wound does not typically occur over a bony prominence, however, can occur on the tops of the toes. Pressure forces play virtually no role in the development of the ulcer, however, for some residents, pressure may play a part. Ischemia is the major etiology of these ulcers. Lower extremity and foot pulses may be diminished or absent.

Venous Ulcers • The wound may start with some kind of minor trauma, such as hitting the leg on a

wheelchair. The wound does not typically occur over a bony prominence, and pressure forces play virtually no role in the development of the ulcer.

Example 1. A resident has three toes on her right foot that have black tips. She does not have diabetes,

but has been diagnosed with peripheral vascular disease.

Coding: Code M1030 as 3. Rationale: Ischemic changes point to the ulcer being vascular.

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M1040: Other Ulcers, Wounds and Skin Problems

Item Rationale Health-related Quality of Life

• Skin wounds and lesions affect quality of life for residents because they may limit activity, may be painful, and may require time-consuming treatments and dressing changes.

• Many of these ulcers, wounds and skin problems can worsen or increase risk for local and systemic infections.

Planning for Care • This list represents only a subset of skin conditions or changes that nursing homes will

assess and evaluate in residents. • The presence of wounds and skin changes should be accounted for in the interdisciplinary

care plan. • This information identifies residents at risk for further complications or skin injury.

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M1040: Other Ulcers, Wounds and Skin Problems (cont.)

Steps for Assessment 1. Review the medical record, including skin care flow sheets

or other skin tracking forms. 2. Speak with direct care staff and the treatment nurse to

confirm conclusions from the medical record review. 3. Examine the resident and determine whether any ulcers,

wounds, or skin problems are present.

• Key areas for diabetic foot ulcers include the plantar (bottom) surface of the foot, especially the metatarsal heads (the ball of the foot).

Coding Instructions Check all that apply in the last 7 days. If there is no evidence of such problems in the last 7 days, check none of the above. Pressure ulcers/injuries coded in items M0200 through M0300 should not be coded here.

• M1040A, Infection of the foot (e.g., cellulitis, purulent drainage)

• M1040B, Diabetic foot ulcer(s) • M1040C, Other open lesion(s) on the foot (e.g., cuts,

fissures) • M1040D, Open lesion(s) other than ulcers, rashes, cuts

(e.g., bullous pemphigoid) • M1040E, Surgical wound(s) • M1040F, Burn(s)(second or third degree) • M1040G, Skin tear(s) • M1040H, Moisture Associated Skin Damage (MASD)

(e.g., incontinence-associated dermatitis (IAD), perspiration, drainage)

• M1040Z, None of the above were present

DEFINITIONS DIABETIC FOOT ULCERS Ulcers caused by the neuropathic and small blood vessel complications of diabetes. Diabetic foot ulcers typically occur over the plantar (bottom) surface of the foot on load bearing areas such as the ball of the foot. Ulcers are usually deep, with necrotic tissue, moderate amounts of exudate, and callused wound edges. The wounds are very regular in shape and the wound edges are even with a punched-out appearance. These wounds are typically not painful. SURGICAL WOUNDS Any healing and non-healing, open or closed surgical incisions, skin grafts or drainage sites. OPEN LESION(S) OTHER THAN ULCERS, RASHES, CUTS Most typically skin lesions that develop as a result of diseases and conditions such as syphilis and cancer. BURNS (SECOND OR THIRD DEGREE) Skin and tissue injury caused by heat or chemicals and may be in any stage of healing.

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M1040: Other Ulcers, Wounds and Skin Problems (cont.) Coding Tips

M1040B Diabetic Foot Ulcers • Diabetic neuropathy affects the lower extremities of individuals with diabetes. Individuals

with diabetic neuropathy can have decreased awareness of pain in their feet. This means they are at high risk for foot injury, such as burns from hot water or heating pads, cuts or scrapes from stepping on foreign objects, and blisters from inappropriate or tight-fitting shoes. Because of decreased circulation and sensation, the resident may not be aware of the wound.

• Neuropathy can also cause changes in the structure of the bones and tissue in the foot. This means the individual with diabetes experiences pressure on the foot in areas not meant to bear pressure. Neuropathy can also cause changes in normal sweating, which means the individual with diabetes can have dry, cracked skin on his other foot.

• Do not include pressure ulcers/injuries that occur on residents with diabetes mellitus here. For example, an ulcer caused by pressure on the heel of a diabetic resident is a pressure ulcer and not a diabetic foot ulcer.

M1040D Open Lesion(s) Other than Ulcers, Rashes, Cuts • Open lesions that develop as part of a disease or condition and are not coded elsewhere

on the MDS, such as wounds, boils, cysts, and vesicles, should be coded in this item. • Do not code rashes, abrasions, or cuts/lacerations here. Although not recorded on the

MDS assessment, these skin conditions should be considered in the plan of care.

• Do not code pressure ulcers/injuries, venous or arterial ulcers, diabetic foot ulcers, or skin tears here. These conditions are coded in other items on the MDS.

M1040E Surgical Wounds • This category does not include healed surgical sites and healed stomas or lacerations that

require suturing or butterfly closure as surgical wounds. PICC sites, central line sites, and peripheral IV sites are not coded as surgical wounds.

• Surgical debridement of a pressure ulcer does not create a surgical wound. Surgical debridement is used to remove necrotic or infected tissue from the pressure ulcer in order to facilitate healing. A pressure ulcer that has been surgically debrided should continue to be coded as a pressure ulcer.

• Code pressure ulcers that require surgical intervention for closure with graft and/or flap procedures in this item (e.g., excision of pressure ulcer with myocutaneous flap). Once a pressure ulcer is excised and a graft and/or flap is applied, it is no longer considered a pressure ulcer, but a surgical wound.

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M1040: Other Ulcers, Wounds and Skin Problems (cont.)

M1040F Burns (Second or Third Degree) • Do not include first degree burns (changes in skin color only).

M1040G Skin Tear(s) • Skin tears are a result of shearing, friction or trauma to the skin that causes a separation of

the skin layers. They can be partial or full thickness. Code all skin tears in this item, even if already coded in Item J1900B.

• Do not code cuts/lacerations or abrasions here. Although not recorded on the MDS, these skin conditions should be considered in the plan of care.

M1040H Moisture Associated Skin Damage (MASD) • MASD is also referred to as maceration and includes

incontinence-associated dermatitis, intertriginous dermatitis, periwound moisture-associated dermatitis, and peristomal moisture-associated dermatitis.

• Moisture exposure and MASD are risk factors for pressure ulcer/injury development. Provision of optimal skin care and early identification and treatment of minor cases of MASD can help avoid progression and skin breakdown.

• MASD without skin erosion is characterized by red/bright red color (hyperpigmentation), and the surrounding skin may be white (hypopigmentation). The skin damage is usually blanchable and diffuse and has irregular edges. Inflammation of the skin may also be present.

• MASD with skin erosion has superficial/partial thickness skin loss and may have hyper- or hypopigmentation; the tissue is blanchable and diffuse and has irregular edges. Inflammation of the skin may also be present. Necrosis is not found in MASD.

• If pressure and moisture are both present, code the skin damage as a pressure ulcer/injury in M0300.

• If there is tissue damage extending into the subcutaneous tissue or deeper and/or necrosis is present, code the skin damage as a pressure ulcer in M0300.

DEFINITION MOISTURE ASSOCIATED SKIN DAMAGE Is superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration.

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M1040: Other Ulcers, Wounds and Skin Problems (cont.)

Examples 1. A resident with diabetes mellitus presents with an ulcer on the heel that is due to pressure.

Coding: This ulcer is not checked at M1040B. This ulcer should be coded where appropriate under the Pressure Ulcers items (M0210–M0300). Rationale: Persons with diabetes can still develop pressure ulcers.

2. A resident is readmitted from the hospital after myocutaneous flap surgery to excise and close his sacral pressure ulcer.

Coding: Check M1040E, Surgical Wound. Rationale: A surgical flap procedure was used to close the resident’s pressure ulcer. The pressure ulcer is now considered a surgical wound.

3. Mrs. J. was reaching over to get a magazine off of her bedside table and sustained a skin tear on her wrist from the edge of the table when she pulled the magazine back towards her.

Coding: Check M1040G, Skin Tear(s). Rationale: The resident sustained a skin tear while reaching for a magazine.

4. Mr. S. who is incontinent, is noted to have a large, red and excoriated area on his buttocks and interior thighs with serous exudate which is starting to cause skin glistening.

Coding: Check M1040H, Moisture Associated Skin Damage (MASD). Rationale: Mr. S. skin assessment reveals characteristics of incontinence-associated dermatitis.

5. Mrs. F. complained of discomfort of her right great toe and when her stocking and shoe was removed, it was noted that her toe was red, inflamed and had pus draining from the edge of her nail bed. The podiatrist determined that Mrs. F. has an infected ingrown toenail.

Coding: Check M1040A, Infection of the foot. Rationale: Mrs. F. has an infected right great toe due to an ingrown toenail.

6. Mr. G. has bullous pemphigoid and requires the application of sterile dressings to the open and weeping blistered areas.

Coding: Check M1040D, Open lesion other than ulcers, rashes, cuts. Rationale: Mr. G. has open bullous pemphigoid blisters.

7. Mrs. A. was just admitted to the nursing home from the hospital burn unit after sustaining second and third degree burns in a house fire. She is here for continued treatment of her burns and for rehabilitative therapy.

Coding: Check M1040F, Burns (second or third degree). Rationale: Mrs. A. has second and third degree burns, therefore, burns (second or third degree) should be checked.

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M1200: Skin and Ulcer/Injury Treatments

Item Rationale

Health-related Quality of Life • Appropriate prevention and treatment of skin changes

and ulcers reduce complications and promote healing.

Planning for Care • These general skin treatments include basic pressure

ulcer/injury prevention and skin health interventions that are a part of providing quality care and consistent with good clinical practice for those with skin health problems.

• These general treatments should guide more individualized and specific interventions in the care plan.

• If skin changes are not improving or are worsening, this information may be helpful in determining more appropriate care.

Steps for Assessment 1. Review the medical record, including treatment records and health care provider orders for

documented skin treatments during the past 7 days. Some skin treatments may be part of routine standard care for residents, so check the nursing facility’s policies and procedures and indicate here if administered during the look-back period.

2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review.

3. Some skin treatments can be determined by observation. For example, observation of the resident’s wheelchair and bed will reveal if the resident is using pressure-reducing devices for the bed or wheelchair.

DEFINITION PRESSURE REDUCING DEVICE(S) Equipment that aims to relieve pressure away from areas of high risk. May include foam, air, water gel, or other cushioning placed on a chair, wheelchair, or bed. Include pressure relieving, pressure reducing, and pressure redistributing devices. Devices are available for use with beds and seating.

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M1200: Skin and Ulcer/Injury Treatments (cont.) Coding Instructions Check all that apply in the last 7 days. Check Z, None of the above were provided, if none applied in the past 7 days.

• M1200A, Pressure reducing device for chair

• M1200B, Pressure reducing device for bed

• M1200C, Turning/repositioning program

• M1200D, Nutrition or hydration intervention to manage skin problems

• M1200E, Pressure ulcer/injury care

• M1200F, Surgical wound care

• M1200G, Application of non-surgical dressings (with or without topical medications) other than to feet. Non- surgical dressings do not include Band-Aids.

• M1200H, Application of ointments/medications other than to feet

• M1200I, Application of dressings to feet (with or without topical medications)

• M1200Z, None of the above were provided

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M1200: Skin and Ulcer/Injury Treatments (cont.)

Coding Tips M1200A/M1200B Pressure Reducing Devices

• Pressure reducing devices redistribute pressure so that there is some relief on or near the area of the ulcer/injury. The appropriate pressure reducing device should be selected based on the individualized needs of the resident.

• Do not include egg crate cushions of any type in this category.

• Do not include doughnut or ring devices in chairs.

M1200C Turning/Repositioning Program • The turning/repositioning program is specific as to the

approaches for changing the resident’s position and realigning the body. The program should specify the intervention (e.g., reposition on side, pillows between knees) and frequency (e.g., every 2 hours).

• Progress notes, assessments, and other documentation (as dictated by facility policy) should support that the turning/repositioning program is monitored and reassessed to determine the effectiveness of the intervention.

M1200D Nutrition or Hydration Intervention to Manage Skin Problems

• The determination as to whether or not one should receive nutritional or hydration interventions for skin problems should be based on an individualized nutritional assessment. The interdisciplinary team should review the resident’s diet and determine if the resident is taking in sufficient amounts of nutrients and fluids or are already taking supplements that are fortified with the US Recommended Daily Intake (US RDI) of nutrients.

DEFINITIONS TURNING/ REPOSITIONING PROGRAM Includes a consistent program for changing the resident’s position and realigning the body. “Program” is defined as a specific approach that is organized, planned, documented, monitored, and evaluated based on an assessment of the resident’s needs. NUTRITION OR HYDRATION INTERVENTION TO MANAGE SKIN PROBLEMS Dietary measures received by the resident for the purpose of preventing or treating specific skin conditions, e.g., wheat-free diet to prevent allergic dermatitis, high calorie diet with added supplementation to prevent skin breakdown, high-protein supplementation for wound healing.

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M1200: Skin and Ulcer/Injury Treatments (cont.) • Additional supplementation above the US RDI has not been proven to provide any further

benefits for management of skin problems including pressure ulcers/injuries. Vitamin and mineral supplementation should only be employed as an intervention for managing skin problems, including pressure ulcers/injuries, when nutritional deficiencies are confirmed or suspected through a thorough nutritional assessment. If it is determined that nutritional supplementation, that is, adding additional protein, calories, or nutrients is warranted, the facility should document the nutrition or hydration factors that are influencing skin problems and/or wound healing and tailor nutritional supplementation to the individual’s intake, degree of under-nutrition, and relative impact of nutrition as a factor overall; and obtain dietary consultation as needed.

• It is important to remember that additional supplementation is not automatically required for pressure ulcer/injury management. Any interventions should be specifically tailored to the resident’s needs, condition, and prognosis.

M1200E Pressure Ulcer/Injury Care • Pressure ulcer care includes any intervention for treating pressure ulcers coded in Current

Number of Unhealed Pressure Ulcers/Injuries at Each Stage (M0300A–G). Examples may include the use of topical dressings; enzymatic, mechanical or surgical debridement; wound irrigations; negative pressure wound therapy (NPWT); and/or hydrotherapy.

M1200F Surgical Wound Care • Does not include post-operative care following eye or oral surgery.

• Surgical debridement of a pressure ulcer does not create a surgical wound. Surgical debridement is used to remove necrotic or infected tissue from the pressure ulcer in order to facilitate healing, and thus, any wound care associated with pressure ulcer debridement would be coded in M1200E, Pressure Ulcer Care. The only time a surgical wound would be created is if the pressure ulcer itself was excised and a flap and/or graft used to close the pressure ulcer.

• Surgical wound care may include any intervention for treating or protecting any type of surgical wound. Examples may include topical cleansing, wound irrigation, application of antimicrobial ointments, application of dressings of any type, suture/staple removal, and warm soaks or heat application.

• Surgical wound care for pressure ulcers that require surgical intervention for closure (e.g., excision of pressure ulcer with flap and/or graft coverage) can be coded in this item, as once a pressure ulcer is excised and flap and/or graft applied, it is no longer considered a pressure ulcer, but a surgical wound.

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M1200: Skin and Ulcer/Injury Treatments (cont.)

M1200G Application of Non-surgical Dressings (with or without Topical Medications) Other than to Feet

• Do not code application of non-surgical dressings for pressure ulcers/injuries other than to feet in this item; use M1200E, Pressure ulcer/injury care.

• Dressings do not have to be applied daily in order to be coded on the MDS assessment. If any dressing meeting the MDS definitions was applied even once during the 7-day look- back period, the assessor should check that MDS item.

• This category may include, but is not limited to, dry gauze dressings, dressings moistened with saline or other solutions, transparent dressings, hydrogel dressings, and dressings with hydrocolloid or hydroactive particles used to treat a skin condition, compression bandages, etc. Non-surgical dressings do not include adhesive bandages (e.g., BAND- AID® bandages, wound closure strips).

M1200H Application of Ointments/Medications Other than to Feet

• Do not code application of ointments/medications (e.g., chemical or enzymatic debridement) for pressure ulcers here; use M1200E, Pressure ulcer/injury care.

• This category may include ointments or medications used to treat a skin condition (e.g., cortisone, antifungal preparations, chemotherapeutic agents).

• Ointments/medications may include topical creams, powders, and liquid sealants used to treat or prevent skin conditions.

• This category does not include ointments used to treat non-skin conditions (e.g., nitropaste for chest pain, testosterone cream).

M1200I Application of Dressings to the Feet (with or without Topical Medications)

• Includes interventions to treat any foot wound or ulcer other than a pressure ulcer/injury.

• Do not code application of dressings to pressure ulcers/injuries on the foot; use M1200E, Pressure ulcer/injury care.

• Do not code application of dressings to the ankle. The ankle is not considered part of the foot.

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M1200: Skin and Ulcer/Injury Treatments (cont.)

Examples 1. A resident is admitted with a Stage 3 pressure ulcer on the sacrum. Care during the last 7

days has included one debridement by the wound care consultant, application of daily dressings with enzymatic ointment for continued debridement, nutritional supplementation, and use of a pressure reducing pad on the resident’s wheelchair. The medical record documents delivery of care and notes that the resident is on a two-hour turning/repositioning program that is organized, planned, documented, monitored, and evaluated based on an individualized assessment of her needs. The physician documents, after reviewing the resident’s nutritional intake, healing progress of the resident’s pressure ulcer, dietician’s nutritional assessment, and laboratory results, that the resident has protein-calorie malnutrition. In order to support proper wound healing, the physician orders an oral supplement that provides all recommended daily allowances for protein, calories, nutrients, and micronutrients. All mattresses in the nursing home are pressure reducing mattresses.

Coding: Check items M1200A, M1200B, M1200C, M1200D, and M1200E. Rationale: Interventions include pressure reducing pad on the wheelchair (M1200A) and pressure reducing mattress on the bed (M1200B), turning and repositioning program (M1200C), nutritional supplementation (M1200D), enzymatic debridement and application of dressings (M1200E).

2. A resident has a venous ulcer on the right leg. During the last 7 days the resident has had a three-layer compression-bandaging system applied once (orders are to reapply the compression bandages every 5 days). The resident also has a pressure reducing mattress and pad for the wheelchair.

Coding: Check items M1200A, M1200B, and M1200G. Rationale: Treatments include pressure reducing mattress (M1200B) and pad (M1200A) in the wheelchair and application of the compression-bandaging system (M1200G).

3. Mrs. S. has a diagnosis of right-sided hemiplegia from a previous stroke. As part of her assessment, it was noted that while in bed Mrs. S. is able to tolerate pressure on each side for approximately 3 hours before showing signs of the effects of pressure on her skin. Staff assist her to turn every 3 hours while in bed. When she is in her wheelchair, it is difficult for her to offload the pressure to her buttocks. Her assessment indicates that her skin cannot tolerate pressure for more than 1 hour without showing signs of the effect of the pressure when she is sitting, and therefore, Mrs. S. is assisted hourly by staff to stand for at least 1 full minute to relieve pressure. Staff document all of these interventions in the medical record and note the resident’s response to the interventions.

Coding: Check M1200C. Rationale: Treatments meet the criteria for a turning/repositioning program (i.e., it is organized, planned, documented, monitored, and evaluated), that is based on an assessment of the resident’s unique needs.

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M1200: Skin and Ulcer/Injury Treatments (cont.) 4. Mr. J. has a diagnosis of Advanced Alzheimer’s and is totally dependent on staff for all of

his care. His care plan states that he is to be turned and repositioned, per facility policy, every 2 hours.

Coding: Do not check item M1200C. Rationale: Treatments provided do not meet the criteria for a turning/repositioning program. There is no notation in the medical record about an assessed need for turning/repositioning, nor is there a specific approach or plan related to positioning and realigning of the body. There is no reassessment of the resident’s response to turning and repositioning. There are not any skin or ulcer treatments being provided.

Scenarios for Pressure Ulcer Coding Example M0100-M1200 1. Mrs. P was admitted to the nursing home on 10/23/2010 for a Medicare stay. In completing

the PPS 5-day assessment, it was noted that the resident had a head-to-toe skin assessment and her skin was intact, but upon assessment using the Braden scale, was found to be at risk for skin breakdown. On the 14-day PPS (ARD of 11/5/2010), the resident was noted to have a Stage 2 pressure ulcer that was identified on her coccyx on 11/1/2010. This Stage 2 pressure ulcer was noted to have pink tissue with some epithelialization present in the wound bed. Dimensions of the ulcer were length 01.1 cm, width 00.5 cm, and no measurable depth. Mrs. P does not have any arterial or venous ulcers, wounds, or skin problems. She is receiving ulcer care with application of a dressing applied to the coccygeal ulcer. Mrs. P. also has pressure reducing devices on both her bed and chair and has been placed on a 1½ hour turning and repositioning schedule per tissue tolerance.

5-Day PPS #1:

Coding:

• M0100B (Formal assessment instrument), Check box. • M0100C (Clinical assessment), Check box. • M0150 (Risk of Pressure Ulcers/Injuries), Code 1. • M0210 (One or more unhealed pressure ulcers/injuries), Code 0 and skip to M1030

(Number of Venous and Arterial Ulcers). • M1030 (Number of Venous and Arterial Ulcers), Code 0. • M1040 (Other ulcers, wounds and skin problems), Check Z (None of the above). • M1200 (Skin and Ulcer Treatments), Check Z (None of the above were provided).

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Scenarios for Pressure Ulcer Coding (cont.)

Rationale: The resident had a formal assessment using the Braden scale and also had a head-to-toe skin assessment completed. Pressure ulcer risk was identified via formal assessment. Upon assessment the resident’s skin was noted to be intact, therefore, M0210 was coded 0. M1030 was coded 0 due to the resident not having any of these conditions. M1040Z was checked since none of these problems were noted. M1200Z was checked because none of these treatments were provided.

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Scenarios for Pressure Ulcer Coding (cont.)

14-Day PPS: Coding: • M0100A (Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-

removable dressing/device), Check box. • M0100B (Formal assessment instrument), Check box. • M0100C (Clinical assessment), Check box. • M0150 (Risk of Pressure Ulcers/Injuries), Code 1. • M0210 (One or more unhealed pressure ulcers/injuries), Code 1. • M0300A (Number of Stage 1 pressure ulcers), Code 0. • M0300B1 (Number of Stage 2 pressure ulcers), Code 1. • M0300B2 (Number of these Stage 2 pressure ulcers present on admission/entry or

reentry), Code 0. • M0300C1 (Number of Stage 3 pressure ulcers), Code 0 and skip to M0300D

(Stage 4). • M0300D1 (Number of Stage 4 pressure ulcers), Code 0 and skip to M0300E

(Unstageable – Non-removable dressing/device). • M0300E1 (Unstageable – Non-removable dressing/device), Code 0 and skip to

M0300F (Unstageable – Slough and/or eschar). • M0300F1 (Unstageable – Slough and/or eschar), Code 0 and skip to M0300G

(Unstageable – Deep tissue injury). • M0300G1 (Unstageable – Deep tissue injury), Code 0 and skip to M1030 (Number of

Venous and Arterial Ulcers). • M1030 (Number of Venous and Arterial Ulcers), Code 0. • M1040 (Other Ulcers, Wounds and Skin Problems), Check Z (None of the above).

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Scenarios for Pressure Ulcer Coding (cont.)

• M1200A (Pressure reducing device for chair), M1200B (Pressure reducing device for bed), M1200C (Turning/repositioning program), and M1200E (Pressure ulcer/injury care) are all checked.

Rationale: The resident had a formal assessment using the Braden scale and also had a head-to-toe skin assessment completed. Pressure ulcer risk was identified via formal assessment. On the 5-day PPS assessment, the resident’s skin was noted to be intact, however, on the 14-day PPS assessment, it was noted that the resident had a new Stage 2 pressure ulcer. Since the resident has had both a 5-day and 14-day PPS completed, the 14-day PPS would be coded 0 at A0310E. This is because the 14-day PPS is not the first assessment since the most recent admission/entry or reentry. There were no other skin problems noted. However, the resident, since she is at an even higher risk of breakdown since the development of a new ulcer, had preventative measures put in place, with pressure reducing devices for her chair and bed. She was also placed on a turning and repositioning program based on tissue tolerance. Therefore, items M1200A, M1200B, and M1200C were all checked. She also now requires ulcer care and application of a dressing to the coccygeal ulcer, so M1200E is also checked. M1200G (Application of nonsurgical dressings [with or without topical medications]) would not be coded here because any intervention for treating pressure ulcers is coded in M1200E (Pressure ulcer/injury care).

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Scenarios for Pressure Ulcer Coding (cont.)

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Scenarios for Pressure Ulcer Coding (cont.)

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Scenarios for Pressure Ulcer Coding (cont.)

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

Pressure Ulcer/Injury Critical Element Pathway

Form CMS 20078 (5/2017) Page 1

Use this pathway for a resident having, or at risk of developing, a pressure ulcer (PU) or pressure injury (PI) to determine if facility practices are in place to identify, evaluate, and intervene to prevent and/or heal pressure ulcers.

Review the following in Advance to Guide Observations and Interviews: The most current comprehensive MDS/CAAs for Sections C - Cognitive Patterns, G – Functional Status, H – Bladder and Bowel, J – Health Conditions-Pain, K – Swallowing/Nutritional Status, M - Skin Conditions-(including history of a pressure ulcers or pressure injuries), and pressure relieving devices.

Physician’s orders (e.g., wound treatment) and treatment record (TAR). Pertinent diagnoses. Care plan (e.g., pressure relief devices, repositioning schedule, treatment, scheduled skin/wound inspection, or pressure ulcer or pressure injury history).

Observations: Observe wound care and assess the wound (observe as soon as possible) o Is the wound care performed in accordance with accepted

standards of treatment, physician’s orders, and care plan? o Is there pain during wound care? If so, what did the nurse do? o Does the wound look infected? o Use of clean gloves and clean technique for each resident. When

treating multiple ulcers on the same resident, provide wound care to the most contaminated ulcer last (e.g., in the perineal region).

o Remove gloves and decontaminate hands between residents. o Staff ensure that if perineal or incontinence care is performed

gloves are used, then visibly soiled dressing is removed, hand hygiene is performed, and clean gloves are donned before clean dressing is applied.

o Clean wound dressing supplies need to be handled in a way to prevent cross-contamination (e.g., wound care supply cart remains outside of resident care areas, unused supplies are discarded or remain dedicated to the resident, multi-dose wound care medications such as ointments, creams should be dedicated to one resident).

o Is hand hygiene and approved glove use practiced when providing wound care? Are precautions taken to not unnecessarily contaminate the wound or clean equipment and supplies during resident care?

o Are reusable dressing care equipment (e.g., bandage scissors) cleaned or reprocessed if shared between residents?

o Has the resident’s skin been exposed to urinary or fecal incontinence? Was the dressing wet or soiled? What did staff do?

How are care planned interventions being implemented? How are staff following the care plan? Is the resident repositioned timely and in the correct position to avoid pressure on an existing PU/PI or areas at risk for developing PU/PI?

Use of proper technique when turning, repositioning, and transferring to avoid skin damage and the potential for shearing or friction.

Pressure relief devices are in place and working correctly and are used per the manufacturer’s instructions.

Does the resident show signs of PU/PI related pain? Are ordered nutritional interventions implemented (e.g., supplements and hydration)?

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

Pressure Ulcer/Injury Critical Element Pathway

Form CMS 20078 (5/2017) Page 2

Resident, Resident Representative, or Family Interview:

Did your wound develop in the facility? If so, do you know how it occurred?

Has staff talked to you about your risk for the wound and how they plan to reduce the risk?

How are they treating your wound? Is the wound getting better? If not, describe. How has your wound caused you to be less involved in activities you enjoy?

How has your wound caused a change in your mood or ability to function?

How did the facility ensure you had a choice in how your wound would be treated?

How often are dressings changed or treatment applied? Does your wound hurt? Do you have pain with wound care or when the dressings are changed? If so, what does staff do for your pain?

What types of interventions are done to help heal your wound? Ask about specific interventions (e.g., positioned q2h, use of pressure redistribution devices or equipment).

If you know the resident refused care: Did staff provide you with other options of treatment or did staff provide you with education on what might happen if you do not follow the treatment plans?

Staff Interviews (Nursing Aides, Nurse, DON, Attending Practitioner):

What, when, and to whom do you report changes in skin condition? Does the resident have a PU? If so, where is it located? How are you made aware of the resident’s daily care needs? What PU interventions are used? Does the resident have pain? If so, how is it being treated? Has the resident had weight loss, dehydration, or acute illness? If so, what interventions are in place to address the problem?

Is the resident currently on any transmission-based precautions? Has there been a change in the resident’s overall function and mood?

Ask about any observation concerns. Is the resident at risk for the development of PU/PI? How and how often is the resident’s skin assessed and where is it documented?

When did the current PU/PI develop? What caused the PU/PI? What interventions were in place before the PU/PI developed? Who was notified of the PU/PI and when were they notified? What is the current treatment ordered by the physician?

What do you do if the resident refuses care? Is the PU/PI improving? How is pain related to the PU/PI assessed? And how often? How do you inform other staff and the MD about the PU/PI status? How do you monitor staff to ensure they are implementing care planned interventions?

How do you determine the appropriate interventions? If there are systemic concerns: What are the facility’s policies and procedures regarding care, treatment, prevention, and interventions for pressure ulcers?

Is the resident’s treatment effective? Have you been contacted with any changes in the PU/PI?

How do you monitor the resident’s wound progress? How is the effectiveness of wound care or pressure ulcer prevention measures evaluated? And how often and by who?

How did you involve the resident in decisions regarding treatments?

Are wound care protocols used? If so, describe.

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

Pressure Ulcer/Injury Critical Element Pathway

Form CMS 20078 (5/2017) Page 3

Record Review: Review nursing notes and/or skin assessments. Did the resident have any unhealed pressure ulcers?

Documentation of the resident’s nutritional needs related to wound healing.

Have nutrition and hydration interventions been put in place? Review laboratory results pertinent to wound healing. Was the MDS accurately coded to reflect the resident’s condition at the time of the assessment? Was a CAA completed to assess the preliminary information gathered in the MDS and determine care planning decisions?

Was a baseline care plan in place within 48 hours of admission, for a resident who was admitted at risk for or had a pressure ulcer on admission?

Was a comprehensive care plan developed? Does it address identified needs, measurable goals, resident involvement and choice, and interventions to heal/prevent pressure ulcers (e.g., pressure relief devices, treatment, and repositioning)? Has the care plan been revised to reflect any changes in PU?

Are interventions and preventive measures for wound healing documented, appropriate, monitored, evaluated, and modified as necessary?

If the resident refuses or resists staff interventions, determine if the care plan reflects efforts to find alternatives to address the needs identified in the assessment.

Has the physician-ordered treatment been evaluated for effectiveness, modified, or changed as appropriate and/or as needed? Was the IDT involved?

Does the wound care documentation reflect the condition of the wound and include the type of dressing, frequency of dressing change, and wound description (e.g., measurement, characteristics)?

Is pain related to PU/PI assessed and treatment measures documented?

Were changes in PU/PI status or other risks correctly identified and communicated with staff and attending practitioner?

Review facility practices, policies, and procedures with regard to identification, prevention, intervention, care, treatment, and correction of factors that can cause PU/PI if concerns are identified.

Was there a significant change in the resident's condition (i.e., will not resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; impacts more than one area of health; requires IDT review or revision of the care plan)? If so, was a significant change comprehensive assessment conducted within 14 days?

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

Pressure Ulcer/Injury Critical Element Pathway

Form CMS 20078 (5/2017) Page 4

Critical Element Decisions:

1) Did the facility ensure that a resident: • Receives care, consistent with professional standards of practice, to prevent pressure ulcers; and • Does not develop pressure ulcers unless the resident’s clinical condition demonstrates that they were unavoidable; and • Receives necessary treatment and services to promote the healing of a pressure ulcer, prevent an infection, and prevent new

ulcers from developing? If No to any of these areas, cite F686

2) Did the physician evaluate and assess medical issues related to the resident’s skin status and supervise the management of all associated medical needs, including participation in the comprehensive assessment process, development of a treatment regimen consistent with current standards of practice, monitoring, and response to notification of change in the resident’s medical status related to pressure ulcers? If No, cite F710

3) Did the facility use appropriate hand hygiene practices and PPE when providing wound/dressing care? If No, cite F880

4) For newly admitted residents and if applicable based on the concern under investigation, did the facility develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident? Did the resident and resident representative receive a written summary of the baseline care plan that he/she was able to understand? If No, cite F655 NA, the resident did not have an admission since the previous survey OR the care or service was not necessary to be included in a baseline care plan.

5) If the condition or risks were present at the time of the required comprehensive assessment, did the facility comprehensively assess the resident’s physical, mental, and psychosocial needs to identify the risks and/or to determine underlying causes, to the extent possible, and the impact upon the resident’s function, mood, and cognition? If No, cite F636 NA, condition/risks were identified after completion of the required comprehensive assessment and did not meet the criteria for a significant change MDS OR the resident was recently admitted and the comprehensive assessment was not yet required.

6) If there was a significant change in the resident’s status, did the facility complete a significant change assessment within 14 days of determining the status change was significant? If No, cite F637 NA, the initial comprehensive assessment had not yet been completed; therefore, a significant change in status assessment is not require OR the resident did not have a significant change in status.

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

Pressure Ulcer/Injury Critical Element Pathway

Form CMS 20078 (5/2017) Page 5

7) Did staff who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident’s status, needs, strengths and areas of decline, accurately complete the resident assessment (i.e., comprehensive, quarterly, significant change in status)? If No, cite F641

8) Did the facility develop and implement a comprehensive person-centered care plan that includes measureable objectives and timeframes to meet a resident’s medical, nursing, mental, and psychosocial needs and includes the resident’s goals, desired outcomes, and preferences? If No, cite F656 NA, the comprehensive assessment was not completed.

9) Did the facility reassess the effectiveness of the interventions and review and revise the resident’s care plan (with input from the resident or resident representative, to the extent possible), if necessary, to meet the resident’s needs? If No, cite F657 NA, the comprehensive assessment was not completed OR the care plan was not developed OR the care plan did not have to be revised.

Other Tags, Care Areas (CA), and Tasks (Task) to Consider: Right to be informed F552, Notification of Change F580, Abuse (CA), Neglect (CA), Choices (CA), Admission Orders F635, General Pathway (CA), Behavioral-Emotional Status (CA), Nutrition (CA), Hydration (CA), Sufficient and Competent Staffing (Task), QAA/QAPI (Task).