1. Pressure Ulcers Avoidability
Saul G. Gruber The Gruber Firm, LLC Mount Laurel, NJ
Advocating for the dignified care of the elderly

2. What is a Pressure Ulcer
A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers.

4. New Stages NPUAP Stage I Red mark Stage II Partial Thickness
Stage III Full Thickness
Stage IV Full Thickness to bone
Deep Tissue Ulcer
Unstageable necrotic

5. Why different in Nursing Homes?
Federal Regulations
42 CFR (C)
OBRA

6. But the Regulations are not the Standard of Care Just a reimbursement guide right?

7. Director of Nursing You had the duty to insure that
there was compliance with the federal and state
regulations within the nursing department;
correct?
A. Correct.
Q. What does that mean?
A. It means to the best of my ability,
I would try to insure compliance with the
regulations.

8. Administrator A. No, I follow the tags. Q. They're the rules?
A. Right.
Q. So we can agree that the books we
have in front of us, at least this watermelon
type book, are the rules -- are part of the rules
of running a nursing home?
A. That we should follow, yes. .

9. Another one
I have a book in front of me, it’s called the Long- Term Care Survey Guide, have you ever seen a book like this book before?
A. Yes.
Q. I presume you own this book?
Q. And within this book, there's also something called F tags, are you familiar with that phrase?
A. Yes.
Q what do they mean? What are the Ftags?
A. F tag, that's the regulation that
you're expected to follow.

10. Standard of care To comply with the regulations Not
Q. Okay. So would you agree with me
that it is the standard of care of the nursing
homes to comply with the federal regulations?
MR. XXXXX: Objection.
THE WITNESS: Yes.
And I'm not saying these represent
the standard of care because there are other
things that go into it, but, certainly, it would
be the standard of care to follow these and the
state regulations; correct?
THE WITNESS: Correct.
To comply with the regulations
Not
The Regulations are the Standard of Care
Get Roy to give the case about standard of care in Virginia

11. 483.25(c)
Pressure Sores Based on the Comprehensive Assessment of a resident, the facility must ensure that (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

12. (c)
Pressure Sores Based on the Comprehensive Assessment of a resident, the facility must ensure that

13. 483.20(b) assessment
Identification Customary routine Cognitive patterns Communication Vision Mood and behavior patterns. Psychological well-being. Physical functioning and structural problems Continence
Disease diagnosis and health conditions. Dental Nutritional status. Skin Conditions Activity pursuit Medications. Special treatments and procedures Discharge potential

14. BRADEN SCALE

15. MDS MINIMUM DATA SET Rate reimbursement New admission within 14 days
Quarterly
Readmission
Significant change in condition

16. MDS
Bring new mds for people to look at

17. Skin Assessments

18. 483.25(c) 1
(1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable;

19. Care plan

20. (c)2
(2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing

21. Flow sheets?

22. F-Tag 314
Avoidable means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.

23. Monitor and Evaluate Interventions
avoidable
Evaluate condition
interventions
Appropriate
Monitor and Evaluate Interventions
Revise when necessary

24. unavoidable
The resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.

25. Ask during depositions of everyone
Look for notations for where acquired
Look for notations regarding avoidability
Make sure pressure not stasis

26. Turning and repositioning
Repositioning is a common, effective intervention for an individual with a pressure ulcer or who is at risk of developing one.29, 30 Assessment of a resident’’s skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care consistent with the resident’’s need and goals. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. The care plan for a resident at risk of friction or shearing during repositioning may require the use of lifting devices for repositioning. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing.

27. How often? In Bed In chair Immobile Every 2 hours at a minimum
Will be in policies and procedures
Immobile
Every 1 hour at a minimum
Will be in policies.

28. Documentation
§483.75(l)(5) the clinical record must contain (i) Sufficient information to identify the resident; (ii) A record of the resident’s assessments; (iii) the plan of care and services provided; (iv)The results of any preadmission screening conducted by the State; (v) progress notes.

29. Why not?
Q. So at the end of the day, when looking at the chart, how could we ever determine an ulcer is avoidable or unavoidable when we don't even know if turning and repositioning was done? A. I don't know.

30. nutrition
483.25(i)
NPUAP
Lab results

31. Pressure relieving mattresses
Foam Mattress Air Mattress Low Air Mattress Alternating Air Mattress Clinitron Bed

32. Additional guides OBRA-Federal Regulations
AMDA-Medical Director Association
NPUAP-National Pressure Ulcer Advisory Panel
WOCN- Wound Ostomy and Continent Nurses
AHCRQ

33. Why?