CMS’s New Guidance for Pressure Ulcers: What It Means
|BY TODD HUTLOCK, ASSISTANT EDITOR|
|CMS’s new guidance for pressure ulcers: What it means|
Interview with Courtney H. Lyder, ND, GNP, FAAN
| On November 12, 2004, the Centers for Medicare & Medicaid Services (CMS) issued a new guidance to surveyors on the care and treatment of pressure ulcers, totally replacing the old text used to cite facilities under F-Tag #314. In addition, F-Tag #309 now includes definitions of ulcers that aren’t pressure related. While much of the new guidance deals with clarifying and defining terminology, the changes have also significantly increased the likelihood of deficiencies being cited. Nursing Homes/Long Term Care Management Assistant Editor Todd Hutlock spoke to wound care expert Courtney H. Lyder, ND, GNP, FAAN, to get his take on these changes. In addition to being one of the country’s foremost authorities on wound care, Dr. Lyder was one of two clinicians invited by CMS to sit on the committee that authored the new guidance, making him uniquely qualified to speak on the subject.|
How do you see these changes in the guidance affecting long-term care in general?
What was changed that is going to make this new guidance so much better?
Another big thing is to delineate between the different kinds of ulcers. Quite often, you will see a nursing home mislabel a venous stasis as a pressure ulcer, for example. I think that it is fair to say that in working toward prevention, we spent a lot of time working on accurate assessment as a key. We wanted to make sure that people could identify those factors that may place a specific resident at risk, and to understand that even though there are many nursing homes that use risk-assessment tools, that those tools are limited. Using a risk-assessment tool is great, but users still have to consider other factors that may not be captured in the tool that could place a resident at risk. These factors include history of a previous ulcer and comorbid conditions such as diabetes and coronary artery disease, to name a few.
There are also definitions listed that are not pressure related.
What are some highlights of the prevention section of the new guidance?
We also address advanced directives, which I believe is new to this guidance. We make it a point to specify that just because there is an advanced directive in place, it doesn’t mean that you don’t provide care. We often hear from nursing homes something like the following: “The resident was in the dying process, therefore his ulcer was unavoidable.” And that isn’t right-“palliative care” does not equal “no care.”
What about the treatment section?
One of the things that I personally wanted to clarify is that many nursing homes interpret “daily monitoring” to mean that they should be doing daily dressing changes. The new guidance clearly delineates what we meant by daily monitoring. It doesn’t mean that you necessarily remove the dressing, but you can look to see if the dressing is still intact; if there is any drainage; does the area around the dressing appear to be compromised. Some states had previously interpreted daily monitoring to mean, “Remove the dressing and take a look at the wound,” which is counterproductive to healing.
It strikes me that some nursing home staff members may initially think the new guidance is going to create more work for them but, in reality, it is educating them to make their jobs easier. Would you agree?
In another new item, there is now specific language that says if no progress is made in the wound in a two- to four-week time frame, then the facility should reevaluate the resident and modify the plan of care as needed. That stated time frame is significant. We can’t say what you might need to do, because each individual case is different, but we can say that you should see progress within that time frame.
The other area that we spent a bit of time on was dressings. Moist wound healing is really the optimal way to go. Wet-to-dry dressing is really more for debridement. Many nursing homes still use wet-to-dry as their primary dressing, and we offer a caveat that it may be appropriate in limited circumstances. However, repeated use will slow down the healing process and cause pain.
There are also significant changes in scope and severity. Can you explain those changes?
Beyond that, we give the surveyors more guidance as to what would be appropriate Level 2, Level 3, and Level 4 citations, with more definitions and explanation. For example, we have now added something called Facility Failures. For instance, the failure to recognize or address the potential for developing a pressure ulcer, independent of an ulcer being there, can get you a Level 2 citation. The failure to implement a comprehensive care plan for a resident who has a pressure ulcer can get you a Level 3 citation. Development of an avoidable Stage IV ulcer can get you a Level 4 citation.
Do you forsee any potential problems with implementation of the new guidance?
So, in some respects, this guidance was a preventive measure-taking feedback ahead of time as opposed to writing guidance without input and dealing with the complaints later.
Courtney H. Lyder, ND, GNP, FAAN, is Professor of Nursing at the University of Virginia Medical Center, and Professor of Internal Medicine and Geriatrics and Chairman, Department of Acute and Specialty Care of Adults, at the University of Virginia School of Nursing, Charlottesville. To contact Dr. Lyder, call (434) 982-3298. To send your comments to the author and editors, please e-mail firstname.lastname@example.org. To order reprints in quantities of 100 or more, call (866) 377-6454.
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