Welcome back to the CMSCG Blog and the final post in our “Ftag of the Week” for F686 Treatment/ Svcs to Prevent/Heal Pressure Injuries. In this post, Mary Quinn, CMS Compliance Group, Inc. Consultant, provides some helpful tips and reminders.
Review all areas of documentation on a routine basis to ensure consistency. It’s amazing how one site can be described/located. i.e., left and right is frequently entered incorrectly; buttock, ischium and sacrum are not the same location! MD orders, wound assessment notes/forms, progress notes, care plans should all have consistent terminology. This is something we often see during documentation reviews for clients – inconsistencies based on who is documenting.
Another tip – Just because a treatment order is entered, don’t assume it is being documented as administered. Omissions on the treatment records can be problematic and are being cited routinely during recertification surveys.
There is no requirement related to wound rounds/participants, but many facilities have found that including a direct caregiver can provide valuable resident-specific information to assist in the development of a resident-centered plan of care. i.e., abbreviated OOB schedules, avoidance of positioning on area of the wound, resident preferences.
Sometimes things don’t go as planned and residents are out of the building or refuse to allow weekly assessments to be conducted. Facilities need to have a process to document/capture re-attempts to complete the weekly assessment. It is not appropriate to wait for the next scheduled wound rounds. i.e., at the next scheduled/accepted dressing change the “due” weekly assessment/documentation could be re-attempted. The wound note should include information as to why the weekly assessment was not completed on the date it was due.
Refusals of treatment always need to be investigated and reported to the physician. The reasons for refusals should be questioned with any necessary follow-up completed and resident participation in the development of the plan of care is recommended.
Sometimes a simple adjustment to the schedule is beneficial. i.e., resident refusing treatment daily . . . because the treatment is scheduled at the time of resident’s favorite TV program, or the resident simply does not appreciate the staff providing his/her treatment in the early morning hours.
The resident’s cognition should always be taken into account related to refusals; family involvement encouraged, and psych consultation considered to determine the resident’s capacity to make medical decisions.
Evidence of Progress
If a PU/PI fails to show some evidence of progress toward healing within 2-4 weeks, the area and the resident’s overall clinical condition should be reassessed by the Wound MD/Nurse. Facilities get caught up in continuing the same treatment regime for months at a time despite little, if any, improvement to the site. Modification of the treatment interventions should be considered. If the decision is made to continue the current regimen, the rationale for continuing the present treatment should be documented to explain why some, or all, of the plan’s interventions remain relevant despite little or no apparent healing.
Don’t forget about pain management for residents with wounds. The treatment regimen should be evaluated to determine if routine pain medication may be appropriate for administration prior to the treatment and/or around the clock. Ensuring pain is managed helps residents be compliant with dressing changes.
Pressure injuries are a high-risk area for providers and impact your Quality Measures. If you need assistance with improving your pressure injury prevention program, CMS Compliance Group can help. Contact us today to learn more about our Clinical Consulting services.