OASIS Alert

Question: I know that Stage 3 and 4 pressure ulcers never heal and should always be reported at their worst stage, but what about Stage 2 pressure ulcers?

Answer:  Reverse staging a healing pressure is never appropriate, no matter the stage. The Centers for Medicare & Medicaid Services points to the Wound Ostomy Continence Nurses Society (WOCN) for the final word on staging pressure ulcers, and this organization has long held that reverse staging is inappropriate.

In a position statement on pressure ulcer staging, the WOCN clearly indicates that it doesn't support down-staging or reverse staging of granulating pressure ulcers. This is because the full-thickness repair process pressure ulcers go through involves replacing lost normal tissue with granulation tissue.

Also of note: In the response-specific instructions for OASIS item M1307 -- The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge, CMS advises "Do not reverse stage pressure ulcers."

The WOCN position statement includes the following scenario: A granulating Stage 4 pressure ulcer should not be "down-staged" to a Stage 3, because a Stage 3 pressure ulcer, by definition, is one with exposed subcutaneous tissue. Instead, it's more appropriate to report a granulating Stage 4 pressure ulcer as a "granulating Stage 4" or "healing Stage 4."

When the Stage 4 pressure ulcer is completely healed, it can be classified as a "healed Stage 4," which indicates that the pressure ulcer is now filled with granulation tissue and resurfaced with epithelium, the WOCN advises.

Bottom line: Stage 1 and Stage 2 pressure ulcers can heal, but should always be reported at their worst stage until healed. Stage 3 and Stage 4 pressure ulcers close, but do not heal, and should also be reported at their worst stage.