Revised Minimum Data Set (MDS) 3.0 Section M: Skin Conditions greatly expands the process of skin assessment in nursing homes. The accompanying Resident Assessment Instrument (RAI) Instruction Manual has instructions on how to identify and code pressure ulcers and other wounds using a methodology that is explicitly stated. These instructions include the following:
“If an ulcer arises from a combination of factors which are primarily caused by pressure, then the ulcer should be included in this section as a pressure ulcer.” (RAI Instruction Manual page M-5)
This theme runs throughout the RAI Manual for MDS 3.0: Skin Condition. In other words, a resident can have severe underlying arterial disease, venous insufficiency, or longstanding diabetes mellitus, but if forces related to pressure precipitated the ulcer’s development the lesion is classified as a pressure ulcer. The effect of this rule is to constrict one’s diagnostic choices when labeling a wound.
But is the language too restrictive? As a clinician and wound care specialist I know that ulcer etiology is multifactorial. Take for example an elderly man with severe pre-existing peripheral atherosclerotic arterial disease who undergoes a major operation and has post-operative life threatening complications. The physiologic factors associated with his acute illness and its treatment can easily cause a watershed effect in areas already underperfused from his atherosclerotic narrowing of the arteries. If he develops an ulcer of his heel, is this a vascular or pressure related lesion?
CMS does provide a small bit of diagnostic wiggle room in the RAI Manual in the discussion of arterial ulcers:
“Pressure forces play virtually no role in the development of the [arterial] ulcer, however, for some residents, pressure may play a part.” (RAI Instruction Manual page M-29)
I predict that the net result of the CMS pressure ulcer classification requirement will have two effects. The first will be to force clinicians to be aware of skin assessment and risk factors for pressure ulcers and encourage pressure relief interventions – the intent of the CMS regulations. But an adverse side effect may be over-diagnosis of lower extremity wounds as pressure ulcers, leading to misclassification along with the risk-management implication of increased lawsuits.
Persons with underlying arterial disease and diabetes mellitus are at increased risk for foot infections, pressure ulcers, gangrene, and amputation. Pressure ulcers are generally viewed as adverse outcomes often associated with poor quality care. If an amputation or gangrene is preceded by a diagnosis of pressure ulcer, a plaintiff attorney will have better leverage for obtaining a favorable settlement or jury award, whether or not the ulcer was associated with poor care.
I certainly do not advocate going against CMS recommendations when assessing wounds in the long-term care setting. What I do advocate is a knowledgeable approach to risk factors, including documentation and quantification of arterial disease with non-invasive vascular studies. The numerous underlying medical conditions leading to vascular compromise and contributing to pressure ulceration must be recognized and documented in the medical record. That, along with proper pressure relief and other preventive interventions, is quality care.
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To access my article on peripheral arterial disease in long-term care click here.