2F309 – Quality of CareEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.No change
3F309 – IntentThe facility must ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident’s right to refuse treatment, and within the limits of recognized pathology and the normal aging process.No change
4DefinitionsImportant to differentiate between a pressure ulcer and a skin ulcer/wound.
5Arterial UlcersArterial Ulcer – non-pressure related disruption or blockage of the arterial blood flow.Underlining cause may be:Moderate to severe peripheral vascular disease.Generalized arteriosclerosis.Inflammatory or autoimmune disorder.Significant vascular disease elsewhere.
6Arterial Ulcer Characteristics: Painful Distal portion of the lower extremityMay be over ankle or bony areas of the footWound bed is dry and pale with minimal or no exudate.Diminished/absent pedal pulseCool to touchPain/blanching on elevationHair lossToenail thickening
7Diabetic Neuropathic Ulcer Requires the resident to be diagnosed with diabetes mellitus and have peripheral neuropathy.Characteristically occurs on the foot.
8Venous Insufficiency Ulcer (Stasis Ulcer) Open lesion of the skin and subcutaneous tissue of the lower leg usually occurring in the pre-tibial area of the lower leg or above the medial ankle.Most common vascular ulceration.Difficult to heal.Venous hypertension is a causative factor.
9F314 – 483.25(c) Part 1 Pressure Sores Based on the Comprehensive assessment of a resident, the facility must ensure that (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable.No change
10F314 IntentPart 1: Residents do not develop pressure ulcers unless they are unavoidable.
11Unavoidable Unavoidable: Assessed Care planned Care plan implemented Evaluation of outcomesCare plan revised
12Unavoidable Multi system organ failure or end of life condition. Not all pressure ulcers are avoidableMulti system organ failure or end of life condition.Refusing care and treatment.
13F314 – 483.25(c) Part 2 Pressure Sores A resident having pressure sores receives the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.
14F314 – Intent Part 2: The facility provides care and services to: Promote healing of current ulcers.Promote prevention.Prevent infection.Prevent development of additional pressure ulcers.
15DefinitionsPressure ulcer – lesion caused by unrelieved pressure that results in damage to the underlying tissue.Friction/shear – contributing factors.
16Assessment Assessment (Initial and ongoing) Identify risk factors (the at risk resident can develop a pressure ulcer within 2 to 6 hours of the onset of pressure.)Which can be removed/modified?Identify pre-existing signs (purple or very dark area surrounded by profound redness, edema, induration, bogginess, coolness, increased warmth.)
18Assessment Evaluate current skin condition. Evaluate underlying medical conditions.Consider intrinsic factors do to aging.Decreased subcutaneous tissueEvaluate the nature of the pressure to which the resident maybe subjected.Pressure intensityPressure durationTissue tolerance
19Assessment Frequency Suggestion Significant number of pressure ulcers develop within the first 4 weeks of admission.Use a standardize risk assessment on admissionRepeat weekly for the first 4 weeksRepeat quarterlyRepeat whenever there is a change
20InterventionsComprehensive assessment provides the basis for defining approaches.Effective prevention and treatment are based upon consistently providing routine and individualized interventions.Care plan with relevant goals and approaches to stabilize/improve co-morbidities.
21InterventionsResident choice – discuss choices with resident and/or family.Advanced DirectiveDoes not prevent the facility from giving supportive, pertinent care.
22Interventions Basic/Routine care: Redistribute pressure (repositioning, protecting heels.)Minimize exposure to moisture, keep skin clean.Provide appropriate pressure redistributing , support surfacesProvide non-irritating surfacesMaintain or improve nutrition and hydration status, where feasible
23Interventions Repositioning Resident may need supportive devices to facilitate position changes.At least every 2 hours or more frequently – dependent on tissue tolerance.Elevating the chair back/head on bed greater then 30 degrees is comparable to sitting.
24InterventionsTeach a resident to shift weight every 15 minutes while sitting in chair.Wheelchairs with sling seats are not optimal for prolonged sitting.Momentary pressure relief does not allow sufficient capillary refill and tissue perfusion.
25Interventions Support Surfaces and Pressure Redistribution Distribute load over a surface or contact area.Pressure reduction (reduction of interface pressure, not necessarily below capillary closure pressure)Pressure relief (reduction of interface pressure below capillary closure pressure)Effectiveness needs to be evaluated on an ongoing basis.
26InterventionsStatic pressure redistribution devices (solid foam, convoluted foam, gel mattress)Used for resident at risk for pressure ulcer development or delayed healing.Does not eliminate the necessity for periodic repositioning
27Interventions Dynamic pressure reduction surfaces Used when resident cannot assume a variety of positions without bearing weight on a pressure ulcer.Used when resident completely compresses a static device that has retained its original integrity.Pressure ulcer is not healing and it is determined pressure may be contributing to the delay in healing.
28InterventionsFriction – mechanical force exerted on the skin that is dragged across any surface.Shearing – interaction of both gravity and friction against the surface of the skin.
29InterventionsWeight reflects a balance between intake and utilization of energy.Consider:Severity of the nutritional compromiseRate of weight loss or appetite declineProbable causePrognosisProjected clinical courseResident wishes and goals
30InterventionsResident who is nutritionally compromised and has a pressure ulcer:Protein intake 1.2 to 1.5 gm/kg body weightSimple multivitaminClinical observationSome laboratory tests may help – no laboratory test is specific or sensitive enough to warrant serial/repeated testing. (A low albumin level combined with the facility’s lack of supplementation is not sufficient to cite a pressure ulcer deficiency.)
31Interventions Debridement Removal of devitalized/necrotic tissue and foreign matter from a wound – improve/facilitate healing.Autolytic debridementEnzymatic (chemical) debridementMechanical debridementSharp or surgical debridementMaggot debridement therapy
32Interventions Pain Control Pain: Integral component of pressure ulcer prevention and management.Eliminate the causeProvide analgesiaAssessing pain in the cognitively impaired.Individual perception.
33Infection Current literature reports that all Stage II, III, and IV are colonized with bacteria but maynot be infected.
34InfectionColonized – presence of bacteria without the signs and symptoms of an infection.Infected – presence of bacteria in sufficient quantities to overwhelm the defenses of viable tissue and produce the signs and symptoms of infection.
35Infection Classified as infected: If signs and symptoms of infection are presentand/orWound culture contains 100,000 or greater micro-organisms per gram of tissue.Findings such as elevated white blood cell count, bacteremia, sepsis or fever may signal pressure ulcer infection or co-existing infection from a difference source.
36Evaluating At least daily – evaluate and document. Evaluate the ulcer and status of area surrounding the ulcerEvaluate the dressingEvaluate for complications and pain.At least weekly evaluate and document:Location and stagingSizeExudatePainWound bedDescription of wound edges and surrounding tissue
37Evaluating Assessing ulcer: Differentiate the type of ulcer (pressure or non-pressure)StageDescribe/Monitor characteristicsMonitor progressWatch for infectionAssess, treat and monitor painMonitor dressing and treatments
38EvaluatingEschar – thick, leathery, (black or brown color) dead/devitalized tissue. May be loose or firmly adhered to the wound.Slough – Necrotic tissue in the process of separating from the viable portions of the body. Soft, moist, light in color.
39EvaluatingExudate - any fluid that has been forced our of the tissue because of inflammation or injury.Purulent exudate/drainage/discharge – Product of inflammation – contains pus.Serous drainage or exudate – watery, clear, yellowish/tan /pink in color that separates from the blood and presents as drainage.
40EvaluatingGranulation Tissue - Pink-red moist tissue that fills al open wound when it starts to heal. Contains new blood vessels, collagen, fibroblast, and inflammatory cells.
41EvaluatingUndermining – destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at the base than at the skin surface.
42EvaluatingTunneling – passageway of tissue destruction under the skin surface that has an opening at the skin level.Sinus Tract – Cavity or channel underlying a wound that involves an area larger than visible surface of the wound.
43EvaluatingStaging:Stage IStage IIStage IIIStage IVIf eschar and necrotic tissue covering and preventing adequate staging code as Stage IV.
44EvaluatingClean pressure ulcer with adequate blood supply and innervation should show evidence of stabilization or some healing within 2-4 weeks.If no evidence of progress toward healing within 2-4 weeks – reassess.
46F314 – Investigative Protocol Pressure Ulcers Objectives:To determine if the identified pressure(s) ulcer is avoidable or unavoidable.To determine the adequacy of the facility’s intervention and efforts to prevent and treat pressure ulcers.
47F314 Investigative Protocol UseSampled resident having, or at risk of developing a pressure ulcer.If not a pressure ulcer – do not proceed with this protocol.
48F314 Investigative Protocol Procedures:Briefly review the assessment, care plan and orders.ObservationInterviewRecord review
49F314 Investigative Protocol 1. Observation:Do staff consistently implement the care plan over time and across various shifts?Note/follow-up on deviations from the care plan.Note/follow-up on potential negative outcomes.
50F314 Investigative Protocol Look for erythematic or color changes on areas such as the sacrum, buttocks, trochanters, posterior thigh, popliteal area, heels when moved off the area:If noted – return ½ to ¾ hours later determine if characteristics persist.
51F314 Investigative Protocol Potential Negative Outcomes If changes persist and exhibit tenderness, hardness or alteration in temperature from surrounding skin – interview staff:Positioning schedule.Policy and procedure for addressing a Stage I pressure ulcer.
52F314 Investigative Protocol Potential Negative Outcome Look for previously unidentified open areas.Look at resident positioning. Is the resident positioned to avoid pressure on an existing pressure ulcer?Does the facility prevent shearing or friction during transfers, elevation and repositioning?Are pressure-redistribution devices in place and working?
53F314 Investigative Protocol Observe existing ulcer and wound care.Characteristics of the wound and surrounding tissue.Type of debridement.Treatment and infection control practices reflect current standards of practice.Steps taken to clean/protect from contamination by urine or fecal incontinence.Does the clinical record reflect the current status of the ulcer?
54F314 Investigative Protocol Unable to observe due to dressing protocol:Inspect surrounding tissuesMay request the dressing be removed if other information suggests a possible treatment/assessment problem
55F314 Investigative Protocol Resident expresses pain related to the ulcer or treatment:Was the resident assessed for pain?Were preemptive measures taken?Were the preemptive measures effective?
56F314 Investigative Protocol 2. InterviewsResident/family/responsible party:Were they involved in care plan, choices, goals? Do interventions reflect their preferences?Are they aware of the approaches being used?Is there presence of pain? How is it managed?If treatment was refused were they counseled on alternatives, consequences?Are they aware of the history of the pressure ulcer? The cause?
57F314 Investigative Protocol Staff interviews – various shifts:Does the staff have knowledge of prevention and treatment?Do the nursing assistants know what, when, and to whom to report changes in skin condition?Who monitors for the implementation of the care plan?Who monitors treatment, frequency of review and evaluation of the ulcer?
58F314 Investigative Protocol 3. Record Review:Documentation should include:Assessment of overall conditionRisk factorsPresence of existing pressure ulcer
59F314 Investigative Protocol If the resident was admitted or developed an ulcer within 1 to 2 days of admission:Review admission documentation (site, characteristics, tissue damage due to immobility or prior illness, skin condition on day of admission, nutritional history, previous pressure ulcer.)
60F314 Investigative Protocol Resident who subsequently developed or has an existing pressure ulcer:Review documentation (wound site, characteristics , progress and complications.)If no signs of healing within 2 to 4 weeks was the wound/treatment reassessed?
61F314 Investigative Protocol Care plan:Is it individualized?Does it address prevention, care, and treatment?Are there specific interventions, measurable goals, time frames.
62F314 Investigative Protocol Revision of care plan:Is staff monitoring resident’s response to interventions?Is the care plan revised based on resident’s responses, outcomes and needs?
63F314 Investigative Protocol If interventions/care provided appears not to be consistent with recognized standards of practice interview one or more health care practitioners/ professionals (physician, charge nurse, DON.)How was it determined that the chosen interventions were appropriate?
64F314 Investigative Protocol Are there risks identified with this treatment for which there are no interventions?Do changes in condition justify additional or different interventions?How is the effectiveness of the current interventions validated?
65Criteria for Compliance Resident with acquired pressure sore:Assessed (risk factors identified and skin condition)Developed and implemented a plan of care based on the resident needsMonitored and evaluated response to interventionsRevised approaches as appropriateIf not, the pressure ulcer was avoidable. Cite at F314.
66Criteria for Compliance Resident admitted with pressure ulcer, non-healing pressure ulcer, at risk of developing subsequent pressure ulcers:Assessment (risk factors and skin condition)Developed and implemented a plan of care based on resident needsAddress potential infectionMonitor/evaluate responseRevise approaches as appropriateIf not cite at F314.
67F314 Non-compliance May include one or more of the following: Failed to accurately or consistently assess.Failed to identify and address risks for developing pressure ulcers.Failed to implement preventative interventions in accord with the resident’s needs and current standards of practice.
68F314 Non-complianceFailed to provide clinical justification for the unavoidable development or non-healing/delayed healing or deterioration of a pressure ulcer.Failed to provide appropriate interventions, care and treatment to an existing pressure ulcer to minimize infection and promote healing.
69F314 Non-complianceFailed to implement interventions for existing wounds.Failed to notify physician of residents condition or changes in resident’s wound care.Failed to adequately implement pertinent infection management practices.Failed to identify or know how to apply relevant policies and procedures for prevention and treatment.
70Potential tags for Additional Investigation F157 - Notification of changesF272 - Comprehensive assessmentF279 - Comprehensive Care PlansF280 – Comprehensive Care PlansF281 – Services provided in accordance with accepted professional standardsF309 – Quality of care
71Potential tags for Additional Investigation F353 - Sufficient StaffF385 - Physician SupervisionF501- Medical Director
72Severity Determination Key elements for severity determination:1. Presence of harm/negative outcomes or potential for negative outcomes because of lack of appropriate treatment and care.2. Degree of harm (actual or potential) related to the non-compliance.3. The immediacy of correction required.
73Severity Level 4 – Immediate Jeopardy to health/safety. Facility non-compliance has caused or is likely to cause serious injury, harm, impairment, death.Requires immediate correction
74Examples – Level 4 Development of avoidable Stage 4. Admitted with Stage 4 – no healing or deterioration.Stage 3 or 4 with associated soft tissue or systemic infection.Extensive failure in multiple areas of pressure ulcer care.
75Severity Level 3 – Actual harm. Clinical compromise. Decline. Impact resident’s ability to maintain and/or reach highest practicable well-being.
76Examples – Level 3 Development of avoidable Stage 3. Development of recurrent or multiple avoidable Stage 2.Failure to implement the comprehensive care plan for a resident who has a pressure ulcer.
77Severity Level 2 Minimal discomfort. Potential to compromise ability for maintain or reach highest practicable level of well being.Potential for greater harm.
78Examples – Level 2Development of single avoidable Stage 2 that is receiving appropriate treatment.Development of avoidable Stage 1.Failure to implement an element of the care plan – no evidence of decline.Failure to recognize or address the potential for developing a pressure ulcer.
79Severity – Level 1 No actual harm with potential for minimal harm. Does not apply to this regulatory requirement.
80F314 - OverviewResearch into appropriate practices for pressure ulcer prevention and healing.The Clinical Practice GuidelinesGuideline #15The National Pressure ulcer Advisory Panel (NPUAP)
81F314 - Overview The American Medical Directors Association (AMDA) The Quality Improvement OrganizationThe Wound, Ostomy, and Continence Nurses Society (WOCN)The American Geriatrics Society guideline “The Management of Persistent Pain in Older Persons.”