Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
Of the Harmony dubbed “Sweet 16 Quality Measures” that impact SNF Five-Star Rating, Pressure Ulcer falls on the list twice. Once for long stay and once for short stay. Today’s blog will focus on the short stay measure. Many facilities become concerned when they note that their Quality Measures for Patients With New or Worsening Pressure Ulcer (Injury) is elevated above facility benchmarks or national averages. This concern is justified and opens an excellent opportunity to investigate current facility practices for managing, coding and clinical operations. Harmony Healthcare International (HHI) offers the following guidelines to assist facilities:
1) Root Cause Analysis
The first step in drilling down to the root cause of this Quality Measure is to understand how the measure is calculated. This Short Stay Quality Measure is calculated and used both in the Five Star reporting system and the Public Reporting Nursing Home Compare website. The measure specifically focuses on Pressure Ulcers (Injuries) from Stage 2 – 4 that are new or have worsened since admission to the facility.
The key words to remember “new or worsened.”
2) MDS Calculation: Know it
This particular measure is straightforward. It compares any MDS Assessments completed during the look back scan and specifically looks at:
- M0300: Current Number of Unhealed Pressure Ulcers at Each Stage
- M0800: Worsening in Pressure Ulcer Status since Prior Assessment (OBRA or scheduled PPS) or Last Admission/Entry.
- All residents with one or more assessments during the lookback scan.
- Exclusions: Assessments which do not have a usable response – meaning there are no Stage 2 – 4 Pressure Ulcers (Injuries) coded. Assessments with missing information or conflicting data.
On the initial MDS:
- Section G must code bed mobility at limited assist or higher
- Section H must code Bowel incontinence at least occasionally
- Section I codes diabetes
- Section K – K0200A and K0200b place patient at a low Body Mass Index (BMI) with a range of 12 – 19
3) Documentation of Wounds is Critical on Admission
Facilities have long been faced with the challenges of admitting patients with a multitude of issues and these conditions often are in the form of acute skin issues. Reports and documentation received from discharge facilities often do not detail skin issues that might be present. It is critical that the admitting Nurse complete a thorough head to toe skin check on shift of admission.
Harmony Healthcare international (HHI) emphasizes the importance of, at a minimum, providing a detailed description of all open wounds present upon admission, even if the Nurse is unable to initially determine wound, injury or ulcer type. A full assessment including staging and treatment plan should be completed within 48 hours of admission to both allow for clinically appropriate treatment and accurate MDS Coding.
4) Train Nurses on Definition of Pressure Ulcer (injury)
Characteristics, Staging, Confused Conditions and Other Types
Per NPUAP guidelines, pressure ulcer (injury) is defined as localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or a combination of pressure, shear and/or friction. Typically, round or oval in shape.
- Location – typically over bony prominences, but can be anywhere that there is external pressure.
- Distribution – isolated and individual.
- Shape – rounded, crater like. Can resemble the shape of what caused the pressure.
- Depth – partial or full thickness.
- Wound Bed – varies depending on thickness of the ulcer.
- Margins – smooth, regular edge, demarcated.
- Surrounding Tissue – varies. Often non-blanchable.
Developed by the NPUAP. Based upon the deepest tissue injury present. Cannot be accurately staged until the deepest viable tissue layer is visible.
- Unstageable – full thickness loss in which entire the base of the ulcer is covered with slough and/or eschar.
- Stage 1 – intact skin with non-blanchable redness.
- Stage 2 – Partial thickness loss of dermis. Presents as shallow opening with red or pink wound bed. Can present as a blister. There will never be slough or eschar in a stage II pressure ulcer. An easy way to identify the stage II is to remember the three “P”s – pink, partial and painful.
- Stage 3 – full thickness tissue loss. Subcutaneous fat may be visible. Bone, tendon or muscle is NOT visible. Slough may be present, but does not cover entire wound base. May include undermining and tunneling. Depth varies by anatomical location.
- Stage 4 – full thickness tissue loss. Bone, muscle, fascia, ligament or tendon will be visible. May contain slough, but not over the entire wound bed. Often includes undermining and tunneling.
- Deep Tissue Injury – purple or maroon localized area of discoloration, may be blood filled blister due to damage to underlying soft tissue. Caused by pressure and/or shear. Surrounding tissue may be mushy, boggy or painful. Evolution to other stages can be rapid, even with appropriate treatment. Fingers will sink, not rebound upon palpation.
- Mucous Membranes – per NPUAP, these areas cannot be staged because lack of appropriate tissue type does not allow for staging. Therefore, NPUAP determined that these areas are to be classified as mucosal pressure ulcers without a stage identified.
Types of skin breakdown often confused with pressure ulcers:
Due to anatomical locations and presentation, there are several acute skin wounds that can often be mistaken for pressure ulcers. Some of these include:
- Moisture lesions - often found over fatty tissue of the buttocks, inner thigh or groin.
- Incontinence related dermatitis – occurs in fatty tissue of buttocks, thigh and groin. May be over a bony prominence. Appears as blotchy or consolidated. Partial thickness damage, superficial. Margins are typically diffuse and irregular.
- Intertriginous Dermatitis – damage caused by skin on skin friction and perspiration. Typically found below large breasts, groins, under the scrotum or other skin folds. Linear in shape. Partial thickness. Surrounding skin is frequently macerated. Can be painful, itchy or burning.
- Bruise – contusion. Results from injury resulting in blood leaking into the tissue. Skin is intact. May present initially as red, blue or purple. Usually resolves within two weeks.
- Purpura – similar in presentation to a contusion, but not caused by blunt force.
- Ecchymosis – not a bruise. Irregular shape usually appears in blue or purplish patches. Not caused by trauma. Caused by a coagulation deficit.
Other Ulcer Types:
While properly identifying the pressure ulcer is important, it is equally important to be able to accurately identify other ulcer types in order to provide the best treatment and interventions.
- Arterial – caused by lower extremity arterial disease and conditions such as atherosclerosis. There is low blood flow, so the lower extremities appear pale. Typically found on the tips of the toes, around the lateral malleolus and at pressure points from footwear. Present as round with even wound margins. Punched out appearance. Wound bed is pale, non-granulating with slough, eschar or epithelial tissue. Generally minimal to no exudates.
- Venous – caused by peripheral vascular disease and chronic venous insufficiency. Legs appear woody and hard with firm edema. Ulcers typically located on medial lower leg and ankle. Seldom on the foot or above the knee. Present with an irregular shape, superficial initially. Wound base is red, ruddy and granular. Exudate is moderate to heavy.
- Diabetic - caused by peripheral neuropathy associated with diabetes. Typically located on the plantar aspect of the foot, over metatarsal heads, under the heel and areas of the foot exposed to repeated trauma. Shape is well defined, round or oblong and deep. Surrounding tissue is usually callused.
Stay tuned and we will continue to define and refine Quality Measures in our weekly blog posts. Harmony Healthcare International (HHI) is available to provide onsite analysis and associated medical record reviews to help you improve your Quality Measure Scores. Please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413.
References: NPUAP Guidelines – 2014 revised; April2016 update
5th Annual LTPAC Symposium
Featuring Guest Speaker Julia Fox Garrison
Click Here to Register