Pressure ulcers and the MDS “Planning for Care” guidance

The RAI User’s Manual for MDS 3.0 is organized nicely. Chapter 3 is divided into 20 sections, each of which begins with a title (e.g., Section M: Skin Conditions) and a description of the section’s intent. It then proceeds through the section, item by item, giving coding instructions. These start with the Item Rationale, which includes Health-Related Quality of Life and Planning for Care instructions, then move on to Steps for Assessment and Coding Instructions.

Imagine that all you had to guide you in managing pressure ulcers were the Planning for Care instructions of section M. What would you learn? Well, actually, some very important concepts.

SECTION M HIGHLIGHTS

Pressure Ulcer Risk (M0100, M0150. For starters, item M0100, Determination of Pressure Ulcer Risk, sets as its goal that “the care planning process should include efforts to stabilize, reduce, or remove underlying risk factors” (CMS, 2013, p. M-1).

From this first Planning for Care statement we know that determining “underlying risk factors” is important. It is best made using the quality assurance and performance improvement (QAPI) principle of getting to the root of the problem by conducting a root cause analysis (RCA). According to CMS’ QAPI at a Glance guide, “The RCA process leads to digging deeper and deeper—looking for the reasons behind the reasons”(p. 18).

There is a difference between “healed” and “closed.” For example, “unstageable pressure ulcers although ‘closed,’ (i.e., may be covered with tissue, eschar, slough, etc.) would not be considered ‘healed’” (p. M-1). Care planning analysis and interventions should be aggressively pursued when there is damaged tissue, even if the skin is still intact.

Tensile strength is defined as “the greatest longitudinal stress a substance can bear without tearing apart.” Care-planning considerations in section M instruct that “tensile strength of the skin overlying a closed pressure ulcer is 80% of normal skin tensile strength” (p. M-1). To protect the skin from re-injury, aggressive preventive measures should be planned and written into the care plan.

After determining pressure ulcer risk, caregivers are instructed to “monitor the impact of the interventions, and to modify the interventions as appropriate” (p. M-3). If interventions aren’t working, they must be changed. Every caregiver plays a part in this process.

Unhealed Pressure Ulcers (M0210). When preventive measures haven’t worked and a pressure ulcer develops, additional Planning for Care instructions are important.“An existing pressure ulcer identifies residents at risk for further complications or skin injury” (p. M-4). This concept is important because a pressure ulcer is not an isolated issue. It represents multifaceted problems and risk factors that need to be assessed and determined. Look at the risk factors described in M0100 to determine which items should be addressed in the care plan (p. M-4). For example, if staff used the Braden assessment tool in M0100 to determine risk, then they should review the scoring for sensory perception, moisture, activity and mobility levels, nutrition, and friction or shearing; these items should be addressed in the care plan as needed.

The Planning for Care instructions focus facility staff on a systematic approach to pressure ulcer staging. We are to use “an assessment system that provides a description and classification based on anatomic depth of soft tissue damage. This tissue damage can be visible or palpable in the ulcer bed.” Once the numerical stage is determined, we can anticipate healing times (p. M-4). A key word in this instruction is “systematic.” Develop an organized, systematic approach to pressure ulcer management for both the individual resident and the system as a whole. This takes critical-thinking skills, a written plan and monitoring for successful outcomes.

Stage 1 Pressure Ulcers (M0300A). Oh, it’s just a little Stage 1 pressure ulcer! Not according to the Planning for Care section on page M-7. “Development of a Stage 1 pressure ulcer should be one of multiple factors that initiate pressure ulcer prevention interventions.” These measures should already be in place for a resident at risk, but when a Stage 1 is determined, a full review of protocols is warranted.

Stage 2 Pressure Ulcers (M0300B). Have you ever wondered why the MDS asks for the date of onset of the oldest Stage 2 pressure ulcer? According to the Planning for Care section on page M-9, “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.” As part of system management, staff should monitor healing time frames of pressure ulcers to see if they are within expected limits.

In this section we also learn that many Stage 2 pressure ulcers are caused by friction and/or shearing. Care plan interventions should include steps to mitigate friction and shearing accidents as we care for the resident. Lastly, this section has some important instructions that the care plan be individualized, that the interventions be monitored and that they be modified if they are not working.

Federal regulations (42 CFR 483.25[c], F314) require that:

Å resident who is admitted without a pressure ulcer doesn’t develop a pressure ulcer unless clinically unavoidable, and that a resident who has an ulcer receives care and services to promote healing and to prevent additional ulcers. The first step in prevention is the identification of the resident at risk of developing pressure ulcers. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions (State Operations Manual, 2011, “Prevention of Pressure Ulcers”).

Stage 3 and 4 Pressure Ulcers (M0300C, M0300D). When residents have pressure ulcers that have advanced to higher numerical stages, they typically “require more aggressive interventions, including more frequent repositioning, attention to nutritional status, and care that may be more time or staff intensive” (CMS, 2013, p. M-11). Pressure ulcers at these higher levels also create the risk of further complications and additional skin injury, such as local infection, sepsis, fever, immobility, depression and so on. Aggressive, holistic, interdisciplinary care planning is essential at these stages.

Take special note of the May 2013 manual update, where the current standard of practice is now codified in print. The MDS regulation states: “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” (pp. M-11, M-14).

Unstageable Pressure Ulcers (M0300E, M0300G). “Although the pressure ulcer 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” (p. M-15). “Suspected deep tissue injury requires vigilant monitoring because of the potential for rapid deterioration. Such monitoring should be reflected in the care plan” (p. M-19).

Dimensions of Pressure Ulcers (M0610). Accurate measurement of any pressure ulcer assists in determining whether the treatments are working. If the length, width and depth of a pressure ulcer are not declining, then the individualized treatment needs to be evaluated. “Pressure ulcer measurement findings are used to plan interventions that will best prepare the wound bed for healing” (p. M-21).

Most Severe Tissue Type for Any Pressure Ulcer (M0700). It’s important to know which type of tissue a wound bed has. If it is granulation tissue, the wound is healing; if eschar, the wound is degenerating. This section states: “Tissue characteristics of pressure ulcers should be considered when determining treatment options and choices” (p. M-23).

Worsening in Pressure Ulcer Status (M0800). It is difficult to prove that a pressure ulcer is unavoidable, although it can be done under certain circumstances. However, most deterioration occurs either because the treatment protocols aren’t working or, worse, because they aren’t being followed by staff. This section states: “The interdisciplinary care plan should be reevaluated to ensure that appropriate preventative measures and pressure ulcer management principles are being adhered to when new pressure ulcers develop or when pressure ulcers worsen” (p. M-25).

When an in-house pressure ulcer develops or worsens, it’s time to evaluate the facility’s care-delivery systems. Take an honest look at the possibility of a broken system and do it in a way that minimizes blame and avoids staff embarrassment.

Healed Pressure Ulcers (M0900). Once a pressure ulcer heals, celebrate your success! Unfortunately, we must also stay on alert because “pressure ulcers that heal require continued prevention interventions as the site is always at risk for future damage” (p. M-29). “Once a pressure ulcer has healed, it is documented as a healed pressure ulcer at its highest numerical stage…. For care planning purposes, [a] healed Stage 4 pressure ulcer would remain at increased risk for future breakdown or injury and would require continued monitoring and preventative care.”

TO LEARN MORE

The RAI User’s Manual for MDS 3.0, chapter 3, section M, “Skin Conditions,” has a wealth of clinical information to assist staff in the development of their care-delivery system for avoiding and managing pressure ulcers. Using the Planning for Care instructions in section M is a great way to begin evaluating your pressure ulcer management system. Sit down as a clinical, interdisciplinary team to read each item together and discuss how well you integrate these regulations into your system.

RESOURCES

Centers for Medicare & Medicaid Services. (2013, May). Long-term care facility resident assessment instrument user’s manual  (version 3.0). Baltimore: Author. Available at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html.

Centers for Medicare & Medicaid Services. (n.d.). QAPI at a glance. Available at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/QAPIAtaGlance.pdf.

State Operations Manual. (2011). Appendix PP, “Guidance to surveyors for long-term care facilities.” Baltimore: Centers for Medicare & Medicaid Services. Available at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.