Long-Term Care Survey Alert

You have some wiggle room at F314 to avoid citations.

Just because your nursing facility "inherits" a resident's pressure ulcer doesn't mean you also have an automatic F314 tag in the offing--not if you hit the ground running at admission to identify and start healing the ulcer.

Know the regulatory reality:  When a facility admits a resident with a pressure ulcer, "surveyors should determine ... whether he received services and treatment to promote healing and to prevent infection and new ulcers from developing," said Sharon Roberson, RN, MSN, during a Centers for Medicare & Medicaid Services-sponsored Webcast on pressure ulcers.

You want to be "diligent and aggressive" in assessing all residents' skin conditions as soon as they are admitted, regardless of their risk profile, says Peggy Dotson, RN, principal of Healthcare Reimbursement & Strategy in Yardley, PA.

Strategy for success: Assign a nurse or certified nursing assistant to do skin assessments as soon as a resident enters the facility. Otherwise, you'll miss the window of opportunity for identifying skin breakdown at admission. And if that happens, good luck convincing surveyors a pressure ulcer didn't occur on your watch. 

Do a head-to-toe check: Often the nursing staff will turn the person over and check his/her coccyx area for pressure ulcers, says Dotson. "But the person may [also] have skin breakdown in the scapula area, on the back of the head, heels and trochanter area," which you can easily miss, she adds.

Home in on Hospital Patients

Residents admitted from the hospital may already have deep tissue damage that you need to identify and document immediately, says Dotson. That's especially true if the person had an observational stay in the ED. "The emergency room department often holds a patient before admitting him to the hospital or a facility," explains Dotson. "And if an elderly patient stays on a gurney for two to 12 hours without moving sufficiently, he could already have deep tissue damage next to the bone," she notes.

In addition, orthopedic patients are "prime candidates for developing pressure ulcers," says Dotson, because they usually experience prolonged pressure during and after the surgical procedure. "The pressure occurs deep against the bone so the person may not have actual skin breakdown at first," she adds. "The damage takes a while to show up."

Tip: A very small percentage of patients who undergo cardiac bypass surgery develop purple, butterfly-shaped sacral lesions, notes Kathleen Thimsen, RN, ET, MSN, a consultant in Bella Vista, AR.

Document your concern: Identify patients who had OR procedures and document the type of surgery, suggests Dotson. "Then indicate in the nursing notes that staff will be watching the resident for skin breakdown related to the surgery."

Develop an alert system: Identify procedures that residents admitted to your facility commonly undergo, such as hip or knee replacements or cardiovascular surgery, Dotson adds. "Then put those patients on 'alert' when they come to the facility" for extra attention so you can identify and address skin breakdown.

Tip: A chronic wound present at admission may herald a non-pressure wound. And if you identify and treat it as a pressure ulcer, you're setting yourself up for failure in the clinical and survey realms.