Transcript Pressure Ulcers F309 F314

Skin/Pressure Ulcers
F309/F314
Implementation Date
11/12/04
F309 – 483.25 Quality of Care
• Each resident must receive and the facility
must provide the necessary care and
services to attain or maintain the highest
practicable physical, mental, and
psychosocial well-being, in accordance with
the comprehensive assessment and plan of
care.
No change
F309 – Intent
The facility must ensure that the resident
obtains optimal improvement or does not
deteriorate within the limits of a resident’s
right to refuse treatment, and within the
limits of recognized pathology and the
normal aging process.
No change
Definitions
• Important to differentiate between a
pressure ulcer and a skin ulcer/wound.
Arterial Ulcers
• Arterial Ulcer – non-pressure related
disruption or blockage of the arterial blood
flow.
• Underlining cause may be:
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Moderate to severe peripheral vascular disease.
Generalized arteriosclerosis.
Inflammatory or autoimmune disorder.
Significant vascular disease elsewhere.
Arterial Ulcer
• Characteristics:
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Painful
Distal portion of the lower extremity
May be over ankle or bony areas of the foot
Wound bed is dry and pale with minimal or no exudate.
Diminished/absent pedal pulse
Cool to touch
Pain/blanching on elevation
Hair loss
Toenail thickening
Diabetic Neuropathic Ulcer
• Requires the resident to be diagnosed with
diabetes mellitus and have peripheral
neuropathy.
• Characteristically occurs on the foot.
Venous Insufficiency Ulcer
(Stasis Ulcer)
• Open lesion of the skin and subcutaneous
tissue of the lower leg usually occurring in
the pre-tibial area of the lower leg or above
the medial ankle.
• Most common vascular ulceration.
• Difficult to heal.
• Venous hypertension is a causative factor.
F314 – 483.25(c) Part 1
Pressure Sores
• Based on the Comprehensive assessment of
a resident, the facility must ensure that (1) A
resident who enters the facility without
pressure sores does not develop pressure
sores unless the individual’s clinical
condition demonstrates that they were
unavoidable.
No change
F314 Intent
• Part 1: Residents do not develop pressure
ulcers unless they are unavoidable.
Unavoidable
• Unavoidable:
– Assessed
– Care planned
– Care plan implemented
– Evaluation of outcomes
– Care plan revised
Unavoidable
Not all pressure ulcers are avoidable
– Multi system organ failure or end of
life condition.
– Refusing care and treatment.
F314 – 483.25(c) Part 2
Pressure Sores
A resident having pressure sores receives the
necessary treatment and services to
promote healing, prevent infection, and
prevent new sores from developing.
F314 – Intent
Part 2: The facility provides care and services
to:
– Promote healing of current ulcers.
– Promote prevention.
– Prevent infection.
– Prevent development of additional
pressure ulcers.
Definitions
• Pressure ulcer – lesion caused by unrelieved
pressure that results in damage to the
underlying tissue.
• Friction/shear – contributing factors.
Assessment
• Assessment (Initial and ongoing)
– Identify risk factors (the at risk resident
can develop a pressure ulcer within 2 to 6
hours of the onset of pressure.)
• Which can be removed/modified?
– Identify pre-existing signs (purple or very
dark area surrounded by profound
redness, edema, induration, bogginess,
coolness, increased warmth.)
Assessment - Risk Factors
• Impaired/decreased mobility and/or functional
status.
• Co morbid conditions
• Drugs (steroids effect healing)
• Impaired blood flow
• Resident refusal
• Cognitive impairment
• Exposure to urinary/fecal incontinence
• Under nutrition, malnutrition, hydration deficits
• A healed ulcer (Stage III and IV)
Assessment
– Evaluate current skin condition.
– Evaluate underlying medical conditions.
– Consider intrinsic factors do to aging.
• Decreased subcutaneous tissue
– Evaluate the nature of the pressure to which the
resident maybe subjected.
• Pressure intensity
• Pressure duration
• Tissue tolerance
Assessment
Frequency Suggestion
• Significant number of pressure ulcers
develop within the first 4 weeks of
admission.
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Use a standardize risk assessment on admission
Repeat weekly for the first 4 weeks
Repeat quarterly
Repeat whenever there is a change
Interventions
• Comprehensive assessment provides the
basis for defining approaches.
• Effective prevention and treatment are
based upon consistently providing routine
and individualized interventions.
• Care plan with relevant goals and
approaches to stabilize/improve comorbidities.
Interventions
• Resident choice – discuss choices with
resident and/or family.
• Advanced Directive
– Does not prevent the facility from giving
supportive, pertinent care.
Interventions
• Basic/Routine care:
– Redistribute pressure (repositioning, protecting
heels.)
– Minimize exposure to moisture, keep skin
clean.
– Provide appropriate pressure redistributing ,
support surfaces
– Provide non-irritating surfaces
– Maintain or improve nutrition and hydration
status, where feasible
Interventions
• Repositioning
– Resident may need supportive devices to
facilitate position changes.
– At least every 2 hours or more frequently
– dependent on tissue tolerance.
– Elevating the chair back/head on bed
greater then 30 degrees is comparable to
sitting.
Interventions
• Teach a resident to shift weight every 15
minutes while sitting in chair.
• Wheelchairs with sling seats are not optimal
for prolonged sitting.
• Momentary pressure relief does not allow
sufficient capillary refill and tissue
perfusion.
Interventions
• Support Surfaces and Pressure Redistribution
– Distribute load over a surface or contact area.
• Pressure reduction (reduction of interface
pressure, not necessarily below capillary
closure pressure)
• Pressure relief (reduction of interface pressure
below capillary closure pressure)
– Effectiveness needs to be evaluated on an
ongoing basis.
Interventions
• Static pressure redistribution devices (solid
foam, convoluted foam, gel mattress)
– Used for resident at risk for pressure ulcer
development or delayed healing.
Does not eliminate the necessity for periodic
repositioning
Interventions
• Dynamic pressure reduction surfaces
– Used when resident cannot assume a variety of
positions without bearing weight on a pressure
ulcer.
– Used when resident completely compresses a
static device that has retained its original
integrity.
– Pressure ulcer is not healing and it is
determined pressure may be contributing to the
delay in healing.
Interventions
• Friction – mechanical force exerted on the
skin that is dragged across any surface.
• Shearing – interaction of both gravity and
friction against the surface of the skin.
Interventions
• Weight reflects a balance between intake and
utilization of energy.
• Consider:
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Severity of the nutritional compromise
Rate of weight loss or appetite decline
Probable cause
Prognosis
Projected clinical course
Resident wishes and goals
Interventions
• Resident who is nutritionally compromised
and has a pressure ulcer:
– Protein intake 1.2 to 1.5 gm/kg body weight
– Simple multivitamin
– Clinical observation
• Some laboratory tests may help – no laboratory test
is specific or sensitive enough to warrant
serial/repeated testing. (A low albumin level
combined with the facility’s lack of supplementation
is not sufficient to cite a pressure ulcer deficiency.)
Interventions
• Debridement
• Removal of devitalized/necrotic tissue and foreign
matter from a wound – improve/facilitate healing.
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Autolytic debridement
Enzymatic (chemical) debridement
Mechanical debridement
Sharp or surgical debridement
Maggot debridement therapy
Interventions
• Pain Control
• Pain:
– Integral component of pressure ulcer prevention
and management.
– Eliminate the cause
– Provide analgesia
• Assessing pain in the cognitively impaired.
• Individual perception.
Infection
Current literature reports that all Stage II, III,
and IV are colonized with bacteria but may
not be infected.
Infection
• Colonized – presence of bacteria without
the signs and symptoms of an infection.
• Infected – presence of bacteria in sufficient
quantities to overwhelm the defenses of
viable tissue and produce the signs and
symptoms of infection.
Infection
• Classified as infected:
– If signs and symptoms of infection are present
and/or
– Wound culture contains 100,000 or greater
micro-organisms per gram of tissue.
• Findings such as elevated white blood cell
count, bacteremia, sepsis or fever may
signal pressure ulcer infection or co-existing
infection from a difference source.
Evaluating
• At least daily – evaluate and document.
– Evaluate the ulcer and status of area surrounding the
ulcer
– Evaluate the dressing
– Evaluate for complications and pain.
• At least weekly evaluate and document:
– Location and staging
– Size
– Exudate
– Pain
– Wound bed
– Description of wound edges and surrounding tissue
Evaluating
• Assessing ulcer:
– Differentiate the type of ulcer (pressure or nonpressure)
– Stage
– Describe/Monitor characteristics
– Monitor progress
– Watch for infection
– Assess, treat and monitor pain
– Monitor dressing and treatments
Evaluating
• Eschar – thick, leathery, (black or brown
color) dead/devitalized tissue. May be
loose or firmly adhered to the wound.
• Slough – Necrotic tissue in the process of
separating from the viable portions of the
body. Soft, moist, light in color.
Evaluating
• Exudate - any fluid that has been forced our
of the tissue because of inflammation or
injury.
– Purulent exudate/drainage/discharge – Product
of inflammation – contains pus.
– Serous drainage or exudate – watery, clear,
yellowish/tan /pink in color that separates from
the blood and presents as drainage.
Evaluating
• Granulation Tissue - Pink-red moist tissue
that fills al open wound when it starts to
heal. Contains new blood vessels, collagen,
fibroblast, and inflammatory cells.
Evaluating
• Undermining – destruction of tissue or
ulceration extending under the skin edges
(margins) so that the pressure ulcer is larger
at the base than at the skin surface.
Evaluating
• Tunneling – passageway of tissue
destruction under the skin surface that has
an opening at the skin level.
• Sinus Tract – Cavity or channel underlying
a wound that involves an area larger than
visible surface of the wound.
Evaluating
• Staging:
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Stage I
Stage II
Stage III
Stage IV
• If eschar and necrotic tissue covering and
preventing adequate staging code as Stage
IV.
Evaluating
• Clean pressure ulcer with adequate blood
supply and innervation should show
evidence of stabilization or some healing
within 2-4 weeks.
• If no evidence of progress toward healing
within 2-4 weeks – reassess.
PRESSUER ULCER
INVESTIGATIVE PROTOCOL
F314 – Investigative Protocol
Pressure Ulcers
• Objectives:
– To determine if the identified pressure(s) ulcer
is avoidable or unavoidable.
– To determine the adequacy of the facility’s
intervention and efforts to prevent and treat
pressure ulcers.
F314 Investigative Protocol
• Use
– Sampled resident having, or at risk of
developing a pressure ulcer.
• If not a pressure ulcer – do not proceed with
this protocol.
F314 Investigative Protocol
• Procedures:
– Briefly review the assessment, care plan and
orders.
• Observation
• Interview
• Record review
F314 Investigative Protocol
1. Observation:
– Do staff consistently implement the care
plan over time and across various shifts?
• Note/follow-up on deviations from the
care plan.
• Note/follow-up on potential negative
outcomes.
F314 Investigative Protocol
• Look for erythematic or color changes on
areas such as the sacrum, buttocks,
trochanters, posterior thigh, popliteal area,
heels when moved off the area:
– If noted – return ½ to ¾ hours later
determine if characteristics persist.
F314 Investigative Protocol
Potential Negative Outcomes
– If changes persist and exhibit tenderness,
hardness or alteration in temperature
from surrounding skin – interview staff:
• Positioning schedule.
• Policy and procedure for addressing a
Stage I pressure ulcer.
F314 Investigative Protocol Potential
Negative Outcome
• Look for previously unidentified open areas.
• Look at resident positioning. Is the resident
positioned to avoid pressure on an existing
pressure ulcer?
• Does the facility prevent shearing or friction
during transfers, elevation and repositioning?
• Are pressure-redistribution devices in place and
working?
F314 Investigative Protocol
• Observe existing ulcer and wound care.
• Characteristics of the wound and surrounding tissue.
• Type of debridement.
• Treatment and infection control practices reflect
current standards of practice.
• Steps taken to clean/protect from contamination by
urine or fecal incontinence.
• Does the clinical record reflect the current status
of the ulcer?
F314 Investigative Protocol
• Unable to observe due to dressing protocol:
– Inspect surrounding tissues
– May request the dressing be removed if other
information suggests a possible
treatment/assessment problem
F314 Investigative Protocol
• Resident expresses pain related to the ulcer
or treatment:
– Was the resident assessed for pain?
– Were preemptive measures taken?
– Were the preemptive measures effective?
F314 Investigative Protocol
2. Interviews
• Resident/family/responsible party:
– Were they involved in care plan, choices, goals? Do
interventions reflect their preferences?
– Are they aware of the approaches being used?
– Is there presence of pain? How is it managed?
– If treatment was refused were they counseled on
alternatives, consequences?
– Are they aware of the history of the pressure ulcer? The
cause?
F314 Investigative Protocol
• Staff interviews – various shifts:
– Does the staff have knowledge of prevention
and treatment?
– Do the nursing assistants know what, when, and
to whom to report changes in skin condition?
– Who monitors for the implementation of the
care plan?
– Who monitors treatment, frequency of review
and evaluation of the ulcer?
F314 Investigative Protocol
3. Record Review:
– Documentation should include:
• Assessment of overall condition
• Risk factors
• Presence of existing pressure ulcer
•F314 Investigative Protocol
• If the resident was admitted or developed an
ulcer within 1 to 2 days of admission:
– Review admission documentation (site,
characteristics, tissue damage due to immobility
or prior illness, skin condition on day of
admission, nutritional history, previous pressure
ulcer.)
F314 Investigative Protocol
• Resident who subsequently developed or
has an existing pressure ulcer:
– Review documentation (wound site,
characteristics , progress and complications.)
– If no signs of healing within 2 to 4 weeks was
the wound/treatment reassessed?
F314 Investigative Protocol
• Care plan:
– Is it individualized?
– Does it address prevention, care, and
treatment?
– Are there specific interventions,
measurable goals, time frames.
F314 Investigative Protocol
• Revision of care plan:
– Is staff monitoring resident’s response to
interventions?
– Is the care plan revised based on
resident’s responses, outcomes and
needs?
F314 Investigative Protocol
 If interventions/care provided appears not
to be consistent with recognized standards
of practice interview one or more health
care practitioners/ professionals
(physician, charge nurse, DON.)
 How was it determined that the chosen
interventions were appropriate?
F314 Investigative Protocol
– Are there risks identified with this treatment for
which there are no interventions?
– Do changes in condition justify additional or
different interventions?
– How is the effectiveness of the current
interventions validated?
Criteria for Compliance
• Resident with acquired pressure sore:
– Assessed (risk factors identified and skin condition)
– Developed and implemented a plan of care based on the
resident needs
– Monitored and evaluated response to interventions
– Revised approaches as appropriate
• If not, the pressure ulcer was avoidable. Cite at
F314.
Criteria for Compliance
• Resident admitted with pressure ulcer, non-healing
pressure ulcer, at risk of developing subsequent
pressure ulcers:
– Assessment (risk factors and skin condition)
– Developed and implemented a plan of care based on
resident needs
– Address potential infection
– Monitor/evaluate response
– Revise approaches as appropriate
• If not cite at F314.
F314 Non-compliance
• May include one or more of the following:
– Failed to accurately or consistently assess.
– Failed to identify and address risks for
developing pressure ulcers.
– Failed to implement preventative interventions
in accord with the resident’s needs and current
standards of practice.
F314 Non-compliance
• Failed to provide clinical justification for
the unavoidable development or nonhealing/delayed healing or deterioration of a
pressure ulcer.
• Failed to provide appropriate interventions,
care and treatment to an existing pressure
ulcer to minimize infection and promote
healing.
F314 Non-compliance
• Failed to implement interventions for existing
wounds.
• Failed to notify physician of residents condition or
changes in resident’s wound care.
• Failed to adequately implement pertinent infection
management practices.
• Failed to identify or know how to apply relevant
policies and procedures for prevention and
treatment.
Potential tags for Additional
Investigation
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F157 - Notification of changes
F272 - Comprehensive assessment
F279 - Comprehensive Care Plans
F280 – Comprehensive Care Plans
F281 – Services provided in accordance
with accepted professional standards
• F309 – Quality of care
Potential tags for Additional
Investigation
• F353 - Sufficient Staff
• F385 - Physician Supervision
• F501- Medical Director
Severity Determination
• Key elements for severity determination:
– 1. Presence of harm/negative outcomes or
potential for negative outcomes because of lack
of appropriate treatment and care.
– 2. Degree of harm (actual or potential) related
to the non-compliance.
– 3. The immediacy of correction required.
Severity
• Level 4 – Immediate Jeopardy to
health/safety.
– Facility non-compliance has caused or is likely
to cause serious injury, harm, impairment,
death.
– Requires immediate correction
Examples – Level 4
• Development of avoidable Stage 4.
• Admitted with Stage 4 – no healing or
deterioration.
• Stage 3 or 4 with associated soft tissue or
systemic infection.
• Extensive failure in multiple areas of
pressure ulcer care.
Severity
• Level 3 – Actual harm.
– Clinical compromise.
– Decline.
– Impact resident’s ability to maintain and/or
reach highest practicable well-being.
Examples – Level 3
• Development of avoidable Stage 3.
• Development of recurrent or multiple
avoidable Stage 2.
• Failure to implement the comprehensive
care plan for a resident who has a pressure
ulcer.
Severity
• Level 2
– Minimal discomfort.
– Potential to compromise ability for maintain or
reach highest practicable level of well being.
– Potential for greater harm.
Examples – Level 2
• Development of single avoidable Stage 2
that is receiving appropriate treatment.
• Development of avoidable Stage 1.
• Failure to implement an element of the care
plan – no evidence of decline.
• Failure to recognize or address the potential
for developing a pressure ulcer.
Severity – Level 1
• No actual harm with potential for minimal
harm.
– Does not apply to this regulatory requirement.
F314 - Overview
• Research into appropriate practices for
pressure ulcer prevention and healing.
– The Clinical Practice Guidelines
• www.ahrq.gov- Guideline #15
– The National Pressure ulcer Advisory Panel
(NPUAP)
• www.npuap.org
F314 - Overview
– The American Medical Directors Association (AMDA)
• www.amda.com
– The Quality Improvement Organization
• www.medqic.org
– The Wound, Ostomy, and Continence Nurses Society
(WOCN)
• www.wocn.org
– The American Geriatrics Society guideline “The
Management of Persistent Pain in Older Persons.”
• www.healthinaging.org
QUESTIONS