Care delivered in nursing homes is highly regulated, particularly for pressure ulcers.  Whatever your opinion of government regulation, laws governing nursing homes undoubtedly provide added protection for these vulnerable adults across America.  This post will provide a basic explanation of regulations covering pressure ulcers in the nursing home which have been recently revised and expanded.  But first I will provide some definitions of terms.

  • Nursing Home Reform Amendments:  Enacted in 1987, these are the laws which govern nursing home care, and are also known as OBRA ’87.  They are encompassed in the Code of Federal Regulations in CFR 42, §483.
  • Interpretive Guidelines:  These are put together by the Centers for Medicare and Medicaid (CMS) and provide specific instructions to surveyors who enter facilities to determine whether the Federal Regulations are being followed.
  • Surveyor:  A team of investigators (Surveyors) is sent by the State’s Department of Health to investigate (Survey) whether the nursing home is following the regulations.
  • F-Tags(also known as Federal Tags):  If the survey team finds that a regulation is not followed, a citation is issued using an F-Tag which designates the specific regulation.  F-Tag 314 refers to the regulations governing care of pressure ulcers, including prevention. 

Essentials of Revised F-Tag 314  

In 2005, F-Tag 314 was vastly expanded, increasing surveyor authority regarding pressure ulcers.  In addition, surveyors are directed to consider other related Federal Tags during investigations for compliance.  This might include topics such as nutritional care and performance of the medical director.  These regulations provide added incentive for facilities to strengthen their pressure ulcer prevention and treatment procedures.  The following is a brief synopsis of essentials of revised F-Tag 314.
Risk Assessment.  The new F-tag mandates risk-assessment for pressure ulcers on every resident on admission along with a complete body check for pre-existing ulcers.  A risk assessment should be administered on admission, then weekly for one month, then quarterly and annually.  The risk-assessment scale should be repeated whenever there is a change in condition. 

The Prevention Plan.  The most basic prevention plan includes turning and positioning, supplemented by pressure relief devices such as heel pads, seating cushions, mattress overlays, and specialty mattresses.  The new CMS guidelines contain an introduction to support surfaces along with discussions of specific pressure redistribution technologies. Mobilization is essential to pressure ulcer prevention, and involves physical and occupational therapists.  A speech therapy consult may help when determining ability to eat and swallow.  An individualized care plan should be constructed for all residents at risk and those who have ulcers, which should take into pressure relief devices, incontinence management and nutrition.  

Ulcer Documentation and Treatment.  Pressure ulcer documentation should begin on admission if a pressure ulcer is present.  Persons with pressure ulcers require comprehensive medical and nutritional assessment.  The new F-Tag 314 specifically targets physician notification of changes in the resident’s condition including wounds.  Essential to documentation is determining the correct diagnosis, and the new guidelines specifically describe other types of ulcers including arterial, venous, and diabetic wounds.  

Simply stating the stage of the ulcer is insufficient, as description of the wound should be accompanied by measurements of length, width, depth, and notation of odor and presence of drainage.  Wound documentation should also contain a narrative description of the wound, current treatment, and whether it is getting better or worse.  Pain related to wounds is also required by the new CMS Guidelines.   

Photographs can provide supplementary documentation of wounds, but should never replace written descriptions.  Each facility must decide whether photographs should be part of their wound care documentation program, a topic which will be addressed in a future blog post.   

Physician Involvement.  The previous CMS Guidelines to Surveyors were silent on the issue of physician involvement in wound care.  A surveyor can now cite the facility for not notifying the physician of changes (F-157), not using correct products (F-281), not providing adequate physician supervision for wound care (F-385), and not involving the medical director in the wound care program (F-501).   

Was the Ulcer Avoidable?  The new CMS Guidelines contain new, more detailed wording to define whether an ulcer was avoidable or unavoidable.  There are detailed guidelines for surveyors to inquire into ulcer prevention, treatments, care plan revisions, and staff interviews to determine whether there should be citations issues.  Issues of pressure ulcer avoidability will be discussed in a future blog post.  

Nutrition and Hydration.  The discussion of nutrition and hydration comprises over a full page of detail in the new Guidelines, referencing other Federal Tags including F-325 (Nutrition) and F-327 (Hydration).  These Guidelines send a clear message that the nutritionist cannot take a “back seat” in the wound care process.  Nutritional assessments for persons at risk for or having wounds should be timely, with special attention given to malnutrition and weight loss, with provision of proper calories and fluids.    

Resident Choice and Advance Directives.  The new CMS Guidelines broaden the scope of pressure ulcer care by including issues of resident choice and advance directives, recognizing the right of the nursing home resident to make informed choices and refuse treatment.  Facilities are now mandated to discuss the resident’s condition, treatment, expected outcomes, and consequences of refusing treatment with either the resident or legal representative.  Because many residents with pressure ulcers are mentally incapacitated from problems such as advanced dementia or stroke, these provisions strengthen the mandate for family education regarding realistic end-of-life decision making.   

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Related postHow CMS Views Pressure Ulcers in Hospitals.