This section, which is rich with information for the care planning team, has significant implications for survey, payment and publicly-reported information. Because of the significant regulatory and legal implications of assessment related to skin, education and training of staff and assurance of competency in skin assessment, including measuring and staging pressure ulcers is a must. The RAI User's Manual reminds us, "(i)t is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound."
In the RAI User's Manual as well in the guidance associated with F-314, Pressure Sores, CMS stresses the importance of recognizing and evaluating each resident's risk factors, including through approaches such as completing a standardized risk assessment scale and conducting a full body assessment. Determination the etiology of the wound (by the medical provider) helps to ensure an appropriate course of treatment and accurate documentation of the wound on the MDS 3.0.
Section M begins by asking what data were used to determine the resident's level of pressure ulcer risk and then asks if the resident is at risk or not. If a resident is without pressure ulcers, the assessor will skip a great deal of section M. If there are any current ulcers, the assessor will then determine the stage of the ulcers and document (for all except stage I ulcers) whether or not the ulcer was present on admission. Regarding determining present on admission, an ulcer is determined not present on admission (i.e., in-house acquired) if it is new or worsens in the nursing home. Because of this, it is critical that the resident's complete admission skin assessment be well-documented, including the accurate staging of any pressure ulcers. In the event an ulcer is unstageable (due to eschar and/or slough, suspected deep tissue injury [sDTI] or a nonremovable device), the clinician should document as soon as the area becomes stageable. The first time that the area becomes stageable (after debridement, the evolution of the sDTI or the removal of the device, respectively), it will be counted as present on admission. When a resident is hospitalized and the ulcer worsens in the hospital, it would be considered present on admission. The RAI User's Manual offers several examples regarding present on admission and regarding coding M0800, Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA or scheduled PPS) or Last Admission/Entry or Reentry. The coding for these two items truly goes hand and hand and ensuring accuracy requires a keen understanding of the directions. Although documenting whether a pressure ulcer is present on admission (in M0300) does not impact the Quality Measures, the stage 2-4 pressure ulcers documented in M0300 do as does coding indicating a pressure ulcer is new or worsening in M0800.
In M0610, Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Unstageable Pressure Ulcer Due to Slough or Eschar measurements of the pressure ulcer with the largest surface area are recorded. HHI notes that many MDS nurses, when asked, state that they are unsure of what their facility's policy says regarding the measurement of pressure ulcers. In practice, many report that they do not recall entering a width that is longer than length even once since the MDS 3.0 has been implemented. While it is possible that all ulcers in a given facility have a head to toe dimension longer than the dimension perpendicular to it, it seems highly unlikely. It seems more probable that instead the nurse measuring in the wound is considering the longest point of the wound to be the length which is not consistent with the RAI User's Manual guidance regarding measuring. In the RAI User's Manual and on the MDS 3.0 form itself, the assessor is instructed that length is the longest point head to toe and that width is the longest point perpendicular to that.
It is essential that the RAI User's Manual along with the clinical guidance for F-309 and F-314 in Appendix PP of the State Operations Manual be used by the clinical team as resources while reviewing and/or updating skin care policies and procedures (as well as documentation tools). Additionally, the National Pressure Ulcer Advisory Panel (NPUAP) Web site, www.npuap.org, has excellent resources related to pressure ulcers. Key areas on which to focus when reviewing/revising policies and educating staff include measuring and staging pressure ulcers as well as determination of etiology. Additionally, facility leadership should ensure physician/medical provider education regarding this, as well as other, sections of the MDS 3.0. Excellence in skin care (including pressure ulcer prevention and treatment) begin with accurate and thorough assessment of the resident.