pamela louderback, arnp, cws charleen ise, md, … · pamela louderback, arnp, cws charleen ise,...

Pamela Louderback, ARNP, CWS

Charleen Ise, MD, CWS,UHM,ABFM

Documenting Wound Care in the SNF & LTAC to Mitigate Liabilities

Confidential and proprietary information

© 2015 Healogics, Inc. All Rights Reserved

Educational Objectives

• Gain a clear understanding of the importance of the initial and ongoing documentation of wound prevention and treatment for the elderly

• Understand why the SNF and LTACH regulations/requirements are paramount to the rules of documentation

• Understand how a wound specialist can assist with documentation to mitigate liability

2



Pressure Ulcer Incidence & Impact

3



Incidence of Pressure Ulcers

4

Pressure ulcers affect:

• At least 2,000,000 Americans

• An estimated 11% of nursing home residents

• An estimated 7% of patients being cared for by home health agencies

• An estimated 10-15% of patients in acute care facilities



Incidence of Pressure Ulcers

5

Pressure ulcers affect:

• Up to 33% of those with spinal-cord injury

• 30% of these patients have recurring ulcers



The cost of pressure ulcers

• Average cost to heal per pressure ulcer is $5k-$65k

• Overall cost of pressure ulcer is $11B annually

• Average lawsuit settlement for PU is $250k

6



How Attorneys Think

Pressure ulcers have evolved to the status of being a synonym for neglect and/or abuse.

7

O/WM 2002 Mar; 48(3): 46-54



Regulations for Documentation

8



Rules and Regulations Governing Documentation of Wound Prevention and Treatment

SNF Rules that Impact Documentation

F-Tags 309 and 314

MDS 3.0 Section M

Data Collection/Outcomes in LTACH that Impact Documentation

LTRAX

9



F-Tag 309 Indications for Documentation

Assessment and diagnosis will document the underlying condition contributing to ulceration, ulcer edges and wound bed, location, shape, condition of surrounding tissues, particularly the basis for differentiating between pressure and any other etiology

10

From CMS Manual in Federal Register



F-Tag 314 Indications for Documentation

In order to label a pressure ulcer unavoidable, the following must be documented:

• Evaluation of resident clinical condition and risk

factors

• Definition and implemented interventions that match

resident needs, goals and recognized standards of

practice

• Monitoring and evaluation of impact of interventions

• Any revised care strategies indicated by impact of

interventions

11



Are All Pressure Ulcers Avoidable? • Development of pressure ulcers is a

multifactorial process

• Risk-assessment schemes do not always capture the factors that may be responsible for development of a pressure ulcer

• The majority of pressure ulcers are avoidable when patients are properly assessed, and prevention protocols are in place

• Some patients will develop pressure ulcers in spite of best care due to chronic skin failure and other factors

Wound Ostomy and Continence Nurses Society.

Position paper. Avoidable vs. unavoidable pressure ulcers (2009).

12



Risk Factors

• Immobility or inactivity

• Advanced age

• Lack of sensory perception, decreased mental awareness

• Weight loss, poor nutrition and hydration

• Urinary or fecal incontinence

• Excess moisture or dryness

• Medical conditions affecting circulation

• Smoking

• Muscle spasms, pain

• Devices applied, such as braces, etc.

13



Pressure Ulcer Prevention

It is difficult to prevent ulcers in:

• Critically ill residents

• Frail elderly residents

• Terminally ill residents

• Wheelchair dependent residents

• Spinal cord injury residents

14



Skin Assessment

• Pressure points and tissue tolerance

• Impaired circulation

• Regular assessments on at risk residents

15



On Admission Document: What is Seen

• Head to toe assessment at admission and regular intervals

• Describe the alteration in skin integrity

• Describe the wound bed, the drainage, the wound edge and the peri-wound

• Detailed history and etiology identification; there may be other causes than pressure

• Focus on bony prominences and pressure bearing areas

• Check to see if reddened areas blanch

• Document areas of skin that are warmer, cooler, painful, softer, firmer compared to adjacent skin

16



Nutritional and Hydration Deficits

Address specific evidence of deficits:

• Caloric loss: any draining wound leaches calories and protein and requires extra of both

• Weight: underweight or weight loss, but overweight residents may still be undernourished

• Higher blood glucose: negatively impacts wound healing and ability to prevent infection

• Hydration: signs and symptoms of deficit

17



Moisture Impact

• Wetness alone has the effect of macerating the skin, softening the stratum corneum, and increasing susceptibility to friction injury

• Both urine and feces, if left on skin, will cause damage

18



Interventions Considerations

• Consider risk assessment and presence of wounds for preventive and treatment strategies

• Resident choice, resident condition, & advanced directives may dictate that certain interventions are not appropriate

• Document condition, treatment options, anticipated outcomes and consequences when resident refuses treatment

19



Repositioning and Offloading

Organized, planned, documented, monitored and evaluated based on resident’s needs

• Turn and reposition according to the resident’s individualized care plan, within alignment with the facility’s protocols, including use of devices

20



Documenting Wound Care

• Location: be as specific as possible. Use anatomical descriptions and terms. When the ulcer is due to pressure, use bony prominence locations

• Size: measure length first (head to toe). Measure width as longest size perpendicular to length. Measure depth using a q-tip. (Make sure measurements are consistent among all documenters)

• Stage: use NPUAP staging system. If not a pressure ulcer, do not stage. (Caution, wait for physician to diagnose before staging)

21



Documenting continued

• Tunneling/undermining: describe each tunnel by depth and clock location. Describe undermining by to and from clock location and greatest depth

• Drainage: describe amount, type or color and thickness

• Wound bed tissue: describe in terms of type and percentage

• Note if there are underlying structures exposed such as tendon or bone

• Odor: normal or malodorous

• Wound Edge: describe

• Peri-wound: describe

22



Culture Controversy in SNFs Regarding Infection

23

• Erythema, redness, inflammation, induration

• Odor

• Purulence or increased

drainage/exudate

• Increased area/size

• Pain – sometimes pain is the first sign of infection



Following Standard of Practice

• Dressings must address management of exudate, moisture balance and other wound characteristics.

• Treatments should change as appropriate to the nature of the wound

• Clean technique is appropriate in all, but wounds with recent surgical debridement or repair

• Wet to dry dressings are discouraged except in limited circumstances

• Interventions must be based on current standards of practice and in line with facility policies and procedures, reviewed and approved by Medical Director

24



MDS 3.0 Rules: Pressure Ulcer Staging

25



Guidelines for Pressure Ulcers (MDS 3.0)

• Do not reverse stage

• Consider current and historical levels of tissue involvement

• Do not stage lesions not primarily related to pressure

26



Stage 1 Pressure Ulcer

• Intact skin with non-blanchable redness of a localized area usually over a bony prominence

• Darkly pigmented skin may not have visible blanching

• Color may differ from the surrounding area

27




Partial thickness loss of dermis presenting as:

• Shallow open ulcer

• Red or pink wound bed

• Without slough or granulation tissue

• May also present as an intact or open / ruptured (serous) blister

28



Stage 3 Pressure Ulcer (Granulation Tissue = Stage 3)

• Full thickness tissue loss.

• Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed.

• Slough may be present, but does not obscure the depth of tissue loss.

• May include undermining and tunneling.

29




• Full thickness tissue loss with exposed bone, tendon or muscle.

• Slough or eschar may be present on some parts of the wound bed.

• Often includes undermining and tunneling.

• Depth varies by anatomical location (bridge of nose, ear, occiput, and malleolus ulcers can be shallow).

30



Unstageable due to Slough or Eschar

• Known, but not stageable related to coverage of wound bed by slough and/ or eschar

• Full thickness tissue loss

• Base of ulcer covered by slough (yellow, tan, gray, green or brown) and/ or eschar (tan, brown or black) in the wound bed

31



Suspected Deep Tissue Injury

• Localized area of discolored (darker than surrounding tissue) intact skin.

• Related to damage of underlying soft tissue from pressure and/ or shear.

• Area of discoloration may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

• Deep tissue injury may be difficult to detect in individuals with dark skin tones.

• Blood-filled blisters related primarily to pressure are more likely than serous-filled blisters to be associated with a suspected deep tissue injury.

32



LTACH Use of LTRAX to Collect Data for Outcomes

33



LTRAX Impact on Wound Documentation • Current use is optional, but anticipated

to become standard

• Collects data on a variety of conditions and outcomes

• Compares with other LTACHs, regionally and nationally

• Tracks admission against discharge change in status

• All wounds and skin issues are tracked including etiology, wound patient rate, average wounds per patient, and wound location

• More detailed data is tracked for Pressure Ulcers

34



Pressure Ulcer Documentation for LTRAX Wound evaluations must be made within 3 days of admission and discharge.

More detail collected will allow for detailed comparisons:

• Stage on admission and discharge

• If unstageable, reason unstageable

• Acquired pressure ulcers and stage at discovery

• Pressure Ulcer attack rate by risk

• BWAT Score

• Average change in BWAT Score

• Initial vs discharge volume and average change in volume

35



BWAT Score

Requires Detailed Pressure Ulcer Information:

1. Size

2. Depth

3. Edges

4. Undermining

5. Necrotic Tissue Type

6. Necrotic Tissue Amount

7. Exudate Type

8. Exudate Amount

9. Skin Color Surrounding Wound

10.Peripheral Tissue Edema & Induration

11.Granulation Tissue

12.Epithelialization

36



Take Home Points

37



Take Home Points

1. Don’t promise something in care planning that you can’t reasonably deliver.

2. If it’s not documented, it’s not done.

3. Assure that nursing documentation is an accurate record of each resident encounter, not only for completeness, but for recall should you ever need it.

4. Be sure nursing descriptions and notes match the wound specialist’s and the other nurses.

38



Take Home Points

5. If a record is not complete, you cannot fill in the blanks later from memory.

6. Not all breaks in skin are pressure ulcers. Let the specialist make the diagnosis.

7. Not all pressure ulcers are avoidable, despite what attorneys think.

8. Wound specialists keep up to date on the standards of practice in wound care prevention and treatment, including ongoing education (CMEs) in regulations and new findings in diagnosis and treatment.

39



References • CMS Minimum Data Set (MDS) 3.0, Section M, June 2010. (Slide Show for

training purposes)

• Federal Register: CMS Manual Rev.4, Issued 11-12-04, Effective 11-12-04, Implementation 11-12-04. F309 and F314

• Hill, M. Are You Aware? Are You Prepared? Dermatology Nursing. Oct2002, Vol. 14 Issue 5, p302.

• LTACH Outcomes System: Retrieved from: https://www.ltrax.com/Assessment/LTRAXWound.jsp

• Mayo Clinic. Bedsores (Pressure sores) (2011). Retrieved from http://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=causes

• Meehan, M, and Hill, WM. Pressure Ulcers in Nursing Homes: Does Negligence Litigation Exceed Available Evidence? O/WM 2002 Mar; 48(3): 46-54

• NPUAP. Pressure Ulcer Prevention Points. (2007). Retrieved from http://npuap.org/PU_Prev_Points.pdf

40

http://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=causes

http://npuap.org/PU_Prev_Points.pdf

pamela louderback, arnp, cws charleen ise, md, … · pamela louderback, arnp, cws charleen ise,...

Documents