Skip to content Skip to navigation

Focus On...Pressure Relief & Wound Care

September 1, 2005
by root
| Reprints
Implementing the New CMS Guidelines for Wound Care by Jeffrey M. Levine, MD, AGSF, CMD; Marilyn Peterson, RNC, MSN; and Fay Savino, RN, BSN, MA
focuson Pressure Relief & Wound Ca re

Implementing the new CMS guidelines for wound care

Areas for potential citations are explained by Jeffrey M. Levine, MD, AGSF, CMD; Marilyn Pete rson, RNC, MSN; and Fay Savino, RN, BSN, MA The Centers for Medicare & Medicaid Services' (CMS) new pressure ulcer guidelines for surve yors have arrived. 1 Federal Tag 314 (F314) is replaced completely by a 40-page document that vastly expands protocols for investigating pressure ulcers (see tables 1 and 2 for F-tags applicable prior to and in the new CMS guidelines). 2 In addition, surveyors are directed to consider other F-tags during inves tigations for compliance. The volume of detail written into the new F314 is extraordinary and essentially amoun ts to a "clinical practice guideline" for wound care directed to both facility staff and surveyors. Along with the Quality Measures posted on CMS's Nursing Home Compare Web site (, these guidelines increase the incentive for f acilities to strengthen their wound care programs.

We suggest that facilities first become familiar with the guidelines, and then completely review their internal systems for wound care, including the policy and pro cedure (P&P) manual. Good wound care is dependent on many aspects of the care process, and this is reflected in the new CMS guidelines, which include emphasis on resident assessment and care planning. New citations are add ed for lack of physician and medical director involvement with wound care, as described below. Since emphasis i s added on physician notification and the correct use of products, internal review should include the responsiv eness and effectiveness of physician services. Remember that wound care is interdisciplinary and includes not o nly medicine and nursing but also nutrition, rehabilitative services, and social work.

Risk Assessment
Risk assessment is an important component of any wound care program. Risk assessm ent for pressure ulcers should be performed on every resident upon admission along with a complete body check f or preexisting ulcers. The Braden Scale is a popular measure, although others are available. 3 Whate ver scale is employed, it should be administered upon admission, then weekly for one month, and then quarterly. Because the risk for pressure ulcers rises with changes in medical status, the risk-assessment scale should be repeated whenever a medical illness or change in status occurs, including such events as stroke, delirium, fra cture, new onset of diabetes mellitus, or any infection, such as UTI or pneumonia.

Accuracy is critical when performing a risk assessment. When the medical record is reviewed by a surveyor, each subscale should corr espond accurately to the patient's condition at that time. Therefore, in-services on use of the assessment scal e are important components of the wound care program. Conduct in-services for all nurse managers and other indi viduals delegated the task of completing the scale. Quality assurance (QA) review is recommended to ensure accu rate determination of the subscales.

The system for documentation of risk requires facility-wide review, beginning with review and revision of the P&P manual and the charting system's organization. An important cons ideration is the construction of the medical record for ease of review. Risk-assessment results should be congr egated in a separate section, thereby allowing for ease of retrospective review of documentation timeliness and accuracy by QA and survey personnel. An alternative method is to place the risk-assessment documentation withi n the interdisciplinary notes in a clearly marked entry.

The Prevention Plan
The facility should maintain an armamentarium of prevention modalities for residents deemed at risk for pre ssure ulcers. The most basic is the turning and positioning schedule, which is supplemented by pressure-relief solutions such as heel pads, seating cushions, mattress overlays, and specialty mattresses. 4 The ne w CMS guidelines contain an introduction to support surfaces, including static and dynamic pressure-reduction d evices. Static pressure redistribution devices simply are cushioned surfaces, while dynamic devices have intrin sic movement. An example of a dynamic pressure-reduction surface is the alternating pressure air mattress.
< BR>The basic turning and positioning schedule is every two hours, but some patients at risk require even greate r frequency because of compromised tissue tolerance. 5 Whether or not the facility's P&P manual requ ires documentation with turning and positioning flow sheets, an auditing system must exist to enforce facility- wide compliance with turning once a resident is deemed at risk.

Several resident characteristics affect the ease of enforcing a turning schedule. Residents with feeding tubes or those on ventilators, for example, ma y not be turned in the same manner as those not attached to life support. Residents with contractures can be tu rned but may need specially positioned pillows or cushions to maintain proper pressure relief. Thus, an individ ualized care plan can provide a guide to pressure-relief management.