On November 12, 2004, CMS released “Guidance to Surveyors for Long Term Care Facilities.” This regulation is used by both federal and state survey agencies to assess the quality of pressure ulcer care provided to residents in long-term care facilities. Although the Federal Tag 314 (Tag F314) regulation has not changed, the way that CMS interprets it has changed significantly.

Where in the past there was much confusion of the regulations and standards of clinical practice guidelines that where being used as references, the facility staff was confused on what surveyors really wanted. Even the Federal Guidelines and the MDS Guidelines conflicted at times when it came to pressure ulcers. Facility staff is relieved to hear that the new F314 Guidelines are very specific on these issues.

The intent of the regulation is to ensure that a resident does not develop pressure ulcers unless his or her clinical condition rendered the ulcer unavoidable. Moreover, this is stressing that long-term care facilities provide adequate care and services to promote the prevention of pressure ulcer developments; promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible); and prevent development of additional pressure ulcers.

The final part of the treatment section reviews how pressure ulcers heal and provides guidance on tools that have been used to monitor the healing of a pressure ulcer. There is ample discussion related to infection and pain associated with pressure ulcers, and the section concluded with a general review of dressing and treatments. It is noted, however, that the use of wet-to-dry gauze dressings or irrigation may be used appropriately in limited situations but that repeated use may damage healthy granulation tissue in healing ulcers and increase resident pain. The guidelines stress that a facility should be able to demonstrate that the implemented treatment protocols are based upon current standards of care.

Pressure Ulcer Prevention

The prevention section of the interpretative guidance stresses that prevention measures must be individualized and monitored for their effectiveness. The first component of prevention, is the risk assessment, thus, the responsibility of identifying resident risk factors remains with the clinicians. The clinicians need to review the risk factors of the pressure points, tissue tolerance, nutrition and hydration, and moisture to development of pressure ulcers.

The Guidelines recognizes residents’ rights and their choices of advance directives and their relationship to pressure ulcer prevention. Thus, residents do have a right to refuse pressure ulcer care. It is also noted that the presence of a “Do Not Resuscitate” (DNR) order does not mean that prevention measures should not be taken. The prevention section of the interpretative guidance also discusses positioning, support surfaces, pressure redistribution, and daily monitoring of patients at risk for pressure ulcer development.

Pressure Ulcer Treatment

The treatment section of the guidelines focus on the importance of accurate assessment of pressure ulcers. Mainly the guidelines are saying: Ask yourself WHY the pressure ulcer occurred and determine the cause of the wound. Identify pressure ulcers and other chronic ulcers are critically important and need to be classified correctly. Clinicians should not label a venous stasis ulcer a pressure ulcer, since the treatment course may be very different. Further discussions are provided on ulcer characteristics (eg, pain, exudate type, and wound tissue type). The guidelines continue to follow the staging system developed by the National Pressure Ulcer Advisory Panel. This staging system uses a 4-stage approach to classifying level of tissue destruction.

Pressure Ulcer Management

Assessment: The resident should be assessed from head to toe, and this assessment starts on admission and continues throughout the residents stay at least quarterly. The development of an individualized care plan and prevention protocols are developed, implemented and reviewed. If a wound is present, it is assessed, a plan is developed, the implementation of treatment, and the evaluation must be documented.

Products: Formulary development is an important step under the new guidelines and education of the product line being used. Reaching the outcomes/goals is the first choice in choosing the product line, second is staff time to use the products and third is the cost- effectiveness of the product line. After we choose the products we are going to use and develop the formularies, education for all staff involved is the key to success. We need to ensure that staff is using the product correctly and appropriately.

Skin Care: A formal skin care program should include the cleansing, rinsing and application of lotions to maintain the skin integrity. Also an incontinent skin care program is developed and a pressure ulcer treatment program is developed.

Assessing and Reporting of Changes of Condition: The C.N.A.’s must report changes of condition to the Charge Nurses. The Charge Nurses must be held accountable. A formal system includes skin integrity checks occurring upon dressing, undressing and at scheduled bathing times. There must be a program in place for reporting and documenting any change in condition of the skin.

Supervision: The most important step in any program is supervision and must exist to see that the program is carried out as intended to insure quality assurance.