Pressure UlcersAvoidability

Saul G. Gruber The Gruber Firm, LLC Mount Laurel, NJ

Advocating for the dignified care of the elderly

What is a Pressure Ulcer

• A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers.

New StagesNPUAP

• Stage I Red mark

• Stage II Partial Thickness

• Stage III Full Thickness

• Stage IV Full Thickness to bone

• Deep Tissue Ulcer

• Unstageable necrotic

Why different in Nursing Homes?

Federal Regulations

42 CFR 483.25 (C)

OBRA

But the Regulations are not the

Standard of Care

Just a reimbursement guide

right?

Director of Nursing

• You had the duty to insure that

• there was compliance with the federal and state

• regulations within the nursing department;

• correct?

• A. Correct.

• Q. What does that mean?

• A. It means to the best of my ability,

• I would try to insure compliance with the

• regulations.

Administrator

• A. No, I follow the tags.

• Q. They're the rules?

• A. Right.

• Q. So we can agree that the books we

• have in front of us, at least this watermelon

• type book, are the rules -- are part of the rules

• of running a nursing home?

• A. That we should follow, yes.

• .

Another one

Q. I have a book in front of me, it’s called the Long-Term Care Survey Guide, have you ever seen a book like this book before?

A. Yes.

Q. I presume you own this book?

A. Yes.

Q. And within this book, there's also something called F tags, are you familiar with that phrase?

A. Yes.

Q what do they mean? What are the Ftags?

A. F tag, that's the regulation that

you're expected to follow.

Standard of care

• Q. Okay. So would you agree with me

• that it is the standard of care of the nursing

• homes to comply with the federal regulations?

• MR. XXXXX: Objection.

• THE WITNESS: Yes.

• And I'm not saying these represent

• the standard of care because there are other

• things that go into it, but, certainly, it would

• be the standard of care to follow these and the

• state regulations; correct?

• MR. XXXXX: Objection.

• THE WITNESS: Correct.

To comply with the regulations

Not

The Regulations are the Standard of

Care

483.25(c)

Pressure Sores Based on the Comprehensive Assessment of a resident, the facility must ensure that

(1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and

(2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

483.25 (c)

Pressure Sores Based on the Comprehensive Assessment of a resident, the facility must ensure that

483.20(b)assessment

Identification

Customary routine

Cognitive patterns

Communication

Vision

Mood and behavior patterns.

Psychological well-being.

Physical functioning and structural problems

Continence

Disease diagnosis and health conditions.

Dental

Nutritional status.

Skin Conditions

Activity pursuit

Medications.

Special treatments and procedures

Discharge potential

BRADEN SCALE

MDS

MINIMUM DATA SET

• Rate reimbursement

• New admission within 14 days

• Quarterly

• Readmission

• Significant change in condition

MDS

Skin Assessments

483.25(c) 1

(1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable;

Care plan

483.25 (c)2

•(2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing

Flow sheets?

F-Tag 314

• Avoidable means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.

Evaluate condition

Appropriate interventions

Monitor and Evaluate

Interventions

Revise when necessary

avoidable

unavoidable

The resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.

• Ask during depositions of everyone

• Look for notations for where acquired

• Look for notations regarding avoidability

• Make sure pressure not stasis

Turning and repositioning

Repositioning is a common, effective intervention for an individual with a pressure ulcer or who is at risk of developing one.29, 30 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 plan of care consistent with the resident’s �need and goals. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. 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 pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing.

How often?

In Bed

• Immobile

• Every 2 hours at a minimum

• Will be in policies and procedures

In chair

• Immobile

• Every 1 hour at a minimum

• Will be in policies.

Documentation

§483.75(l)(5)

the clinical record must contain

(i) Sufficient information to identify the resident;

(ii) A record of the resident’s assessments;

(iii) the plan of care and services provided;

(iv)The results of any preadmission screening conducted by the State;

(v) progress notes.

Why not?

Q.     So at the end of the day, when looking at the chart, how could we ever determine an ulcer is avoidable or unavoidable when we don't even know if turning and repositioning was done?

      A.     I don't know.

nutrition

•483.25(i)

•NPUAP

•Lab results

Pressure relieving mattresses

Foam Mattress

Air Mattress

Low Air Mattress

Alternating Air Mattress

Clinitron Bed

Additional guides

• OBRA-Federal Regulations

• AMDA-Medical Director Association

• NPUAP-National Pressure Ulcer Advisory Panel

• WOCN- Wound Ostomy and Continent Nurses

• AHCRQ

Why?