Nursing homes are among the most tightly regulated institutions, and any healthcare provider in this setting knows the dreaded F-word…F-tag. (Insert shudder here). Regarding wound care, what used to be F-tag 314 is now F-tag 686. Within the 749 pages of the State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Section 483.25(b) Skin Integrity with 483.25(b)(1) Pressure Ulcers involves twenty pages of explanation. The good news: CMS typically utilizes the terms and definitions established by the National Pressure Ulcer Advisory Panel (NPUAP) and implements those terms and definitions into the Minimum Data Set (MDS). The bad news: Not understanding and following the guidance could be costly.
One of the most critical actions a healthcare provider in long-term care can take is to proactively document all aspects of wound management. Aside from knowing that wound documentation is required at least weekly and having a wound sheet, there are additional aspects of the regulations to know and understand in order to ensure compliance. Several will be highlighted in this blog.
- Concisely document how wound healing is impacted by tissue perfusion, nutritional status, co-morbidities, inflammation, and age, among other factors4. For example to address one section under 483.25(b)(1) which reviews modifiable and nonmodifiable risk factors that “…increase a resident’s susceptibility to develop or to not heal pressure ulcers…”, wound documentation should specifically identify and discuss factors that are present that potentially impede wound healing such as arterial disease, diabetes, end-stage renal disease, medications, etc.).
- Wound documentation should review both the patient’s prognosis as well as the wound prognosis. For example, under Nutrition and Hydration, the 483.25(b)(1) regs state, “continuing weight loss and failure of a pressure injury 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.” Describe how wound healing is impacted by a patient’s end-stage disease that requires a more palliative approach. A great phrase to utilize in documentation is “delayed wound healing expected” with a succinct but clear explanation. Residents with advanced dementia are expected to lose weight as the disease progresses. It is important to connect how advanced or progressive illnesses (i.e., end-stage dementia) impact wound healing for the surveyors. In addition, collaboration with the dietitian to follow the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines, as well as patient-centered nutritional goals, are valuable components in wound documentation.
- Document and describe pressure injuries that occur at the end of life and the Kennedy terminal ulcer (KTU). Powerful pieces of documentation include the location and appearance of the KTU, that appropriate preventative measures were in place, and that the KTU appeared suddenly, within hours. The website, kennedyterminalulcer.com is a great website for further information on this condition. Though skin failure and other end of life skin conditions are not listed or described (example: 3:30 syndrome or Trombley-Brennan terminal tissue injury), surveyors do have two paragraphs explaining potentially unavoidable pressure injuries. As the regs state, “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 pressure injury may be considered unavoidable.” Thus it is critical to explicitly describe in the medical record the wound, its healing potential, and all factors that contribute to or impede wound healing. NPUAP supports not turning residents every two hours at the end of life, emphasizing the importance of documenting why…that turning causes more distress and pain and is not beneficial for comfort at the end of life.
- Documentation should clearly how “resident choices” impact the appropriateness or feasibility of interventions and wound healing. The section, “Resident Choices,” describes how care plans should establish relevant goals and interventions for pressure injury management. In addition, facility staff and practitioners should document clinically valid reasons why an intervention may not be appropriate or feasible. For example, when a patient chooses to smoke despite education on the detrimental effects of smoking on wound healing, the healthcare provider should objectively document that education was provided, that the patient comprehended the education and has chosen to continue to smoke. As an example: “Delayed wound healing expected due to smoking, which causes vasoconstriction and reduces blood flow to the extremity.” The resident has every right to continue smoking. The provider also should absolutely provide the standard of care. The treatment plan will then need to be developed based on the patient’s preference, the goals of care, and what fiscally makes sense.
- Time parameters reflecting the duration of the activity, sitting schedules and progress toward healing should also be documented. The 483.25(b)(1) regulations include comments on specific time recommendations. For example, under “Healing Pressure Ulcer/Injuries”, the regs state, “residents with pressure injuries on the sacrum/coccyx or ischia should limit sitting to three times a day in periods of 60 minutes or less.” Therefore, documentation should include when the patient is in bed and that the patient is in a less than 90-degree position when in the chair or bed. There is wiggle room in the regs that allow for modification of sitting schedules per patient/family preference. Another time interval to be mindful of within the regs: “if a pressure injury fails to show some evidence of progress toward healing within 2-4 weeks, the area and the resident’s overall clinical conditions should be reassessed. Re-evaluation of the treatment plan includes determining whether to continue or modify the current interventions.” A thorough wound evaluation also includes the rationale for the treatment plan, especially when the wound does not appear to be improving using the current treatment plan.
Extra time documenting goes a long way to avoid F-tags, litigation, etc. Wound care is an interdisciplinary effort. Nursing should not be the only profession commenting on pressure injuries (or other wounds for that matter) in nursing homes. Physicians, advanced practice providers, therapists, dietitians, and nursing staff should all be looking at the wounds as well as documenting them. In addition, there should be a consensus on the staging and periodic discussions to ensure everyone is on the same page and agrees with the staging and plan for the pressure injury. Lastly, be consistent with terminology in the documentation. Call a spade a spade…if it’s due to pressure, then it is a pressure injury, and everyone should describe it as such. The F-word (i.e. F-tag) does not have to be a dirty word in long-term care if the team is documenting appropriately.