MDS Alert

How to navigate the standard of care and MDS requirements.

Over- or understaging pressure ulcers can lead to a breakdown in your facility's payment, compliance and survey record. To ensure staff is on the right page in staging pressure ulcers -- and have the documentation to back up their decisions -- consider these three strategies.

1. Know what to look for to stage a decub. The RAI manual defines a stage 2 as a "partial thickness loss of skin layers that presents clinically as an abrasion, blister, scab or shallow crater." By contrast,  a stage 3 ulcer has full thickness loss of skin, exposing subcutaneous tissue. There may or may not be undermining of adjacent tissues, states the manual. But the ulcer is "still in the subcutaneous tissue," says Mary Arnold Long, MSN, RN, CRRN, CWOCN, APRN-BC,CLNC, a wound care specialist in Mason, OH. "Subcutaneous tissue is fat, so it's going to appear yellow."

Key point: When staging a pressure ulcer, "it's really important to identify the anatomical structures of the wound," emphasizes Long.

A stage 4 pressure ulcer goes through the subcutaneous tissue so that you see exposed underlying organs. Arnold says she often hears people say that if the bone hasn't been exposed, it's not a stage 4. But if you can see a ligament or tendon, the wound is a stage 4, Long emphasizes. "If the patient has orthopedic hardware exposed in the pressure ulcer, that's also a stage 4."

2. Reconcile MDS-required reverse staging with the standard of care. To complete the MDS, you have to follow the instructions for downstaging pressure ulcers, which require you to stage a decub as it appears during the seven-day lookback in Section M.

The reverse staging scheme ratchets down payment as an ulcer heals -- and it shows surveyors that a decub has improved.

You can devise documentation systems to follow the standard of care, which doesn't include reverse staging, while also meeting RAI manual requirements.

Example: "If a stage 4 is granulated and filled with connective tissue, the MDS requires you to code that as a stage 3," says Arnold. "But a pressure ulcer is never less than it was once -- a stage 4 is always a stage 4." So if the pressure ulcer appears as a stage 3 and was a 4, code and document it as a stage 3 for purposes of completing the MDS, suggests Arnold.

"But within the narrative notes or wound assessment document, if the facility has a separate form, state 'This is a resolving stage 4 that now appears as a stage 3" -- or 'this is a healing stage 4 in the granulating stage that now appears as a stage 3.'''

That documentation strategy recognizes "that the wound was a stage 4 and has the potential to deteriorate," says Arnold. She notes that even though "the pressure ulcer gets to a maturational phase of healing, which can take up to two years to complete, the skin tensile strength in that area will never be the same as it was pre-injury," leaving it more vulnerable to breaking down.

Coding reminder: Code a "1" for "yes" at M3 if the resident has a history of a resolved/cured pressure ulcer within the last 90 days.

Relief in sight: The draft MDS 3.0 does away with reverse staging of pressure ulcers (see the Clip And Save article in this issue).

3. Use a collaborative approach in staging pressure ulcers. Consulting with a wound care nurse expert can help ensure facility staff stage pressure ulcers accurately.

Examples: The facility where Daniel Haimowitz, MD, CMD, works has a dedicated wound nurse reassess pressure ulcers to see if she agrees with the staging. She also serves as a resource if staff have a question about staging a pressure ulcer -- "or when there's a conflict about how to stage a pressure ulcer," says Haimowitz, who practices in Levittown, PA.

A team at Venturan Convalescent Center discusses how to stage a pressure ulcer on the MDS as part of a weekly wound review meeting, reports Renee Jones, RN, the director of nursing at the facility in Ventura, CA. Jones, the MDS coordinator and staff development representatives attend the meeting.