The Kennedy Terminal Ulcer (KTU) has been around for over two decades, and continues to play a large part in discussions as to whether pressure ulcers are avoidable or unavoidable. Until now the Center for Medicare and Medicaid Services (CMS) has not acknowledged the KTU in its regulatory and reimbursement guidelines for hospitals and nursing homes. In a new transmittal from CMS, the KTU can now be used to avoid reporting a pressure ulcer as a quality measure in Long-Term Care Hospitals (LTCHs). This step goes a long way in legitimizing the concept that certain medical conditions can lead to unavoidable pressure ulcers that are not indicative of inadequate quality of care.


Long-Term Care Hospitals (LTCHs) are also known as Long-Term Acute Care Hospitals (LTACs) or “transitional care hospitals.” These are facilities licensed as acute care hospitals with additional Medicare certification that supports a length of stay more than 25 days. The LTCH is sometimes the only choice for people who have been in an acute-care hospital but are too sick to return home or go to a skilled nursing facility (SNF) or rehabilitation setting. LTCH patients are medically complex, and because of the heavy burden of co-morbidities one can expect wound care to be a common concern.


A quality reporting program has already been in effect for Medicare Certified Skilled Nursing Facilities (SNFs) through mandatory documentation in the Minimum Data Set. CMS has recognized that several conditions in hospitals are reasonably preventable, and will not pay for Hospital Acquired Conditions (HACs) that include Stage 3 and 4 pressure ulcers.


Section 3004 of the Patient Protection and Affordable Care Act passed in 2010 mandated a Quality Reporting Program (QRP) for Long-Term Care Hospitals, Inpatient Rehabilitation Hospitals, and Hospice programs. The final rule for submission of quality data by LTCHs was published August 18, 2011 in Volume 76 of the Federal Register. CMS recognized three quality indicators for LTCHs: 1) Catheter-Associated Urinary Tract Infections, 2) Central line Catheter-Associated Blood Stream Infections, and 3) Pressure Ulcers that are New or Have Worsened. The Kennedy Terminal Ulcer was not mentioned in this final rule, however it is incorporated into a draft of the LTCH Quality Reporting Program Manual recently released and available on the CMS website.


The LTCH Quality Reporting Program Manual mandates data collection beginning on January 1, 2014. The Pressure Ulcer quality measure requirement is fulfilled by completing the Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluations (CARE) Data Set. The skin section of the CARE Data Set is designated Section M, and is very similar to requirements in the Minimum Data Set (MDS) that apply to Medicare Certified Skilled Nursing Facilities. One major exception is found in the Coding Tips, where the Kennedy Terminal Ulcer is specifically mentioned:


“Skin ulcers that develop in patients who have terminal illness or are at the end of life should be assessed and staged as pressure ulcers until it is determined that the ulcer is part of the dying process (also known as Kennedy ulcers). Kennedy ulcers can develop from 6 weeks to 2 to 3 days before death. These ulcers present as pear-shaped purple areas of skin with irregular borders that are often found in the sacrococcygeal areas. When an ulcer has been determined to be a Kennedy Ulcer, it should not be coded as a pressure ulcer.”


These instructions potentially eliminate (based on resident assessment), new pressure ulcers in persons who are expected to die from quality indicator reporting in Long-Term Acute Care hospitals.


Over one hundred years ago, Jean-Martin Charcot described the decubitus ominosus, or the pressure ulcer that heralds death. The term Kennedy Ulcer was coined in the 1980’s by Dr. Stephen Glassley, medical director of Byron Health Center where Karen led a wound care team. I have previously stated that there is an array of physiological disturbances and co-morbidities that allow pressure ulcers to occur even in the best of circumstances. CMS has now informed us that the dying process can suspend the designation of pressure ulcers as a quality indicator in Long Term Care Hospitals. Is it now time to apply similar criteria to other healthcare environments, and broaden our recognition of other factors that can render the occurrence of pressure ulcers unavoidable?


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Download my article:  The Unavoidable Pressure Ulcer: A Retrospective Case Series.
Download the final rule that requires submission of quality indicator data for LTCHs.
Download Section M: Skin Conditions from the LTCH Reporting Program Manual that mentions the Kennedy Terminal Ulcer.
Go to the Kennedy Terminal Ulcer website.
Learn more about the Hospital Acquired Conditions.
Download the Consensus Statement on Skin Changes at Life’s End (SCALE).
Download general information on LTCH Quality Reporting.


Related posts:


Pressure ulcer as “Never Event”: Fact or Myth?
Historical Roots of the Avoidable-Unavoidable Pressure Ulcer Controversy.
New Research Sheds Light on Hospital Acquired Pressure Ulcers.
Determining the Avoidability of Pressure Ulcers.
How CMS Views Pressure Ulcers in Hospitals.


Special thanks to Elizabeth Ayello PhD, RN who called my attention to this news and provided references for this post.