MDS Alert

Make this smart move when dealing with a deceptive decub.

Envision this: A post-op patient comes in the facility with a purplish, boggy area over a bony prominence, which the nurse correctly records as a stage 1 pressure ulcer since the overlying skin is intact. But within several days, the patient's stage 1 ulcer has turned into a gaping decubitus ulcer, prompting his family to complain to the state health department.

Beware: If you don't have the right documentation to tell "the rest of the story" about that ulcer, the facility may be looking at an actual harm tag or even immediate jeopardy.

Turn the Top-Down Theory On Its Head

Surveyors who see that a wound has gone from a 2 to a 3 or a 3 to a 4 may believe the wound is worse. And while that's a "wonderful theory," it's not necessarily true, says Mary Arnold Long, MSN, RN, CRRN, CWOCN, APRN-BC, CLNC, a wound care specialist in Mason, OH.  She notes there's the "top-down theory where an untreated stage 1 becomes a stage 2 and a 3, etc.," but evidence exists to support that the more serious wounds -- stage 3 to 4 -- actually "begin at the bone-muscle interface," says Arnold. And that's more of a "bottom-up phenomenon.

"Potentially the patient could have had that deep tissue damage at the bone-muscle interface and no matter what interventions you use, that pressure ulcer will become a 3 or 4" within three to five days, says Arnold.

Survey survival assessment tip: With the new F314 guidelines in effect, "it's absolutely critical to get an accurate assessment of the skin from head-to-toe, especially looking for any signs of pressure ulcers" at admission, says Jane Belt, MSN, RN, a consultant with Plante & Moran Clinical Group in Columbus, OH. The facility doesn't want to take "credit" for something that did not occur there, she says.

Document Carefully

Documentation can help you head off an actual harm tag for a stage 1 pressure ulcer that you know will become a serious ulcer in short order. "Describe very clearly how the skin looks and feels," advises Gail Robison, RN, RAC-C, a legal nurse consultant with Boyer and Associates in Brookfield, WI. You can also document in such cases that the person appears to have a deep tissue injury and it appears it will deteriorate in spite of interventions, advises Arnold.

Tip: Feel the resident's heels to see if they are "mushy," because mushy skin can break down very quickly, adds Robison.

Continue to assess and document daily the condition of the area that appears to have deep tissue damage.  Also document your care plan interventions, says Robison.

"Under the revised F314 survey guidance," you have to reassess a stage 1 ulcer each day "so you'd be keeping a close eye on something you're not sure about [in terms of whether the skin damage is more extensive than a stage 1]," Robison suggests.

As part of the record, also document "where the resident was admitted from, which helps differentiate inherited versus acquired pressure-related skin damage," adds Patricia Boyer, RN, NHA, principal of Boyer and Associates.  Stay tuned: The National Pressure Ulcer Advisory Panel (NPUAP) is having a conference in February 2007 and will  discuss the phenomenon of deep tissue injury.