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CMS's New Guidance for Pressure Ulcers: What It Means

March 1, 2005
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Interview with Courtney H. Lyder, ND, GNP, FAAN
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?
Dr. Lyder:
The new guidance is much more comprehensive versus the one in place prior to November 12, 2004. In many ways, the document gives surveyors more direction. I think it is much clearer as to what surveyors will be looking for in nursing homes. I think there will be a lot less "wiggle room," so to speak-fewer gray areas. We've tried to make the interpretive guidance much more prescriptive. It also addresses some new areas: For example, it now addresses residents receiving palliative care and what the expectations should be related to their skin care. We tried to use as much up-to-date information as possible. I feel it is a much better working document than the previous guidance.

What was changed that is going to make this new guidance so much better?
Dr. Lyder:
I think that the reemphasis we have now placed on prevention is very important-the whole idea of preventing ulcers and identifying residents who are at risk. We wanted to make sure that the surveyors understood some of the main concepts around skin care and pressure ulcer prevention and treatment. The first section focuses on definitions-making sure that the surveyors understand, for example, when a report says "tunneling," they know exactly what that means. We want everyone to be on the same page with terminology and make sure that everyone is using the terms correctly.

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.
Dr. Lyder:
Right. I can't tell you off the top of my head what the percentage is, but from our observations and based on what the surveyors on our panel said, many times nursing home staff are mislabeling wounds as pressure ulcers. The more educated they are across the board, the better the resident outcomes are going to be.

What are some highlights of the prevention section of the new guidance?
Dr. Lyder:
We call special attention to the importance of nutrition and identifying residents who are undernourished, as well as the effects of moisture. These are key risk factors.

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?
Dr. Lyder:
Again, we are stressing that you know what type of ulcer you are treating-pressure versus nonpressure, etc. There is quite a bit on staging, but staging only tells you the initial insult. We do also identify much more clearly than in the past what the minimal expectations are for describing the ulcer, i.e., the wound bed, slough or no slough, exudate amount, etc. We now provide clear guidance on monitoring so they are able to describe the ulcer, as well as clarifying some of the characteristics we are looking for in their descriptions.

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.

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