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Pressure ulcers and the MDS “Planning for Care” guidance

September 18, 2013
by Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE
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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.


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: