The revised Resident Assessment Instrument (RAI) with the new MDS 3.0 Section M: Skin Conditions radically expands the assessment process for pressure ulcers in Medicare certified skilled nursing facilities. In contrast to the prior version, there are data fields for improving or deteriorating pressure ulcers, ulcer measurements, and tissue type at the base of the wound. Important issues such as “present on admission” and updated staging categories such as unstageable and suspected deep tissue injury have been incorporated. One thing that is not addressed in MDS 3.0 is whether the ulcer was avoidable or unavoidable.
This does not mean, however, that the interdisciplinary team cannot address the important issue of whether the pressure ulcer could have been avoided. The revised RAI Users Manual states that the MDS is only the beginning of the assessment process, and is continued in the Care Assessment Area (CAA). Facilities are encouraged to utilize an identified set of current resources for further assessment. These resources can include clinical practice guidelines, textbooks, articles, or other guide books.
If an interdisciplinary team (IDT) wants to incorporate determination of unavoidability into their assessment, the CAA is the place to do it. First identify your resources which contain standards for unavoidability, which should include the wording from revised F-Tag 314, supplemented by other resources if necessary. You can find some resources on my blog post: Determining the Avoidability of Pressure Ulcers. It is advisable that the physician be part of this assessment process, as factors leading to unavoidable pressure ulcers may include multiple comorbidities and physiological disturbances such as severe anemia, hypoxia, hypotension, hypoalbuminemia, etc.
The process for determination of unavoidability should be documented in the medical record. Facilities should establish a documentation process that works for them, that incorporates the necessary tools and resources, and provides a written summary that is easily accessible.
So in summary, when it comes to pressure ulcers MDS 3.0 really does avoid the unavoidable, but the resident assessment process does not. The assessment for unavoidability can be incorporated into the Care Assessment Process (CAA) which extends the assessment process which begins with the MDS. The assessment should provide a true picture of the nursing home resident’s status, and sometimes that picture includes unavoidable pressure ulcers.
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To download my research study on unavoidable pressure ulcers click here.
To read more on revised MDS 3.0 on the CMS website click here.