MDS version 3.0, the mandatory assessment tool for residents of skilled nursing facilities, was finally implemented October 2010 after years of planning. Section M: Skin Condition has been completely revised and expanded. This blog post will address MDS 3.0 sub-section M0100: Determination of Pressure Ulcer Risk, which approaches “at-risk” status in a much more sophisticated and clinically acceptable manner than past versions, enabling better targeting of preventive measures.
MDS 2.0 did not have an evidence-based method for classifying “at-risk” status for pressure ulcers. Determination of “at-risk” status in MDS 2.0 was made by low scores on bed or transfer ADL ability, persons who scored “comatose,” or those with nutritional disorder. The result was a basic flaw in data-gathering and reporting for Quality Indicators and Quality Measures.
MDS 3.0 Makes Clinical Sense on “At-Risk” Assessment
MDS 3.0, sub-section M0100 mandates determination of pressure ulcer risk by one of three methods, all of which make clinical sense. These are discussed as follows:
M0100. A: Resident has a stage 1 or greater, a scar over bony prominence, or a non-removable dressing or device.
This entry recognizes that if a person has a pressure ulcer or a pressure ulcer that has healed, the patient is automatically classified “at-risk.” It makes no sense to score a patient “not at risk” using the Braden Scale or Norton Score in the presence of a pressure sore, then making the illogical conclusion that the patient is not at risk for developing pressure ulcers. M0100 also recognizes that if a patient has a “non-removable device” such as a cast or brace, an automatic “at-risk” score is generated.
M0100. B: Formal assessment instrument/tool (e.g., Braden, Norton, or other).
This entry recognizes that if a patient scores “at-risk” using a formalized assessment tool, that person is considered prone to developing pressure ulcers. This alone is a great improvement over MDS 2.0 criteria.
M0100. C: Clinical assessment
In my opinion this is one of the best innovations of MDS 3.0 Section M. Recognition of pressure ulcer risk independent of standardized assessment tools is a concept I have been advocating for years – and an important one for clinicians to understand. Many medical factors that do not appear on the roster of entries on either the Braden or Norton tools need consideration as contributors to pressure ulcer risk. Pressure ulcers are largely a result of hypoperfusion of the skin, and conditions such as hypotension, severe anemia, and hypoxia contributed their genesis. Other conditions such as longstanding diabetes mellitus, or terminal state can also factor into clinical risk.
In summary, revised Section M: Skin Condition on MDS 3.0 is a complex advance over prior versions. This revised assessment tool contains a clear message that the Braden and Norton scores are not the only factors to consider when determining pressure ulcer risk status. I hope that clinicians in settings other than Medicare certified skilled nursing facilities will learn this lesson.
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For more information on MDS 3.0 please go to the CMS website.