Ftag of the Week – F686 Treatment/Svcs to Prevent/Heal Pressure Injuries (Pt. 3)

Welcome back to the CMSCG “Ftag of the Week” for F686 Pressure Injuries. We hope you had a wonderful Thanksgiving! Let’s get back into what is required for treatment of pressure injuries and the importance of documentation.


A resident has been admitted to your facility with a pressure injury or unfortunately has developed a pressure injury while at the facility – what do you want to ensure is reflected in the medical record?

It is important that the facility has a system in place to assure that the protocols for daily monitoring of each pressure injury site and for periodic documentation are in place and are adhered to on a routine basis. Sounds simple, right?  Then why do facilities encounter difficulty with daily or shift-to-shift monitoring of the pressure injury site and doing a simple documentation task of signing for treatment administration? Maybe because the oversight monitoring of staff completing these tasks needs to be reviewed or staff simply need additional education.

With each dressing change – or at least weekly – an evaluation of the PI should be documented. Changes (improvement, deteriorate, healing) or complications should be documented and communicated when they are observed. That means responsible staff should not wait for routine weekly wound rounds/documentation, so that appropriate changes can be made to the plan of care. Revision to the plan of care needs to be implemented on a timely basis – when identified. This would include observations of changes such as an increased area of ulceration, increased redness or swelling, change or increase in exudate.

As far as routine weekly assessment /documentation, it is recommended that this is completed every 7 days and should contain detailed information, including:

  • Location and staging
  • Size – measured as perpendicular measurements of the greatest extent of length and width of the PU/PI)
  • Depth
  • Presence, location and extent of any undermining or tunneling/sinus tract

If present, include:

  • Exudate – Including the type (e.g., purulent/serous), color, odor and approximate amount
  • Pain – Including the nature and frequency (e.g., whether episodic or continuous)

Documentation should also include:

  • Wound bed, including:
    • Color
    • Type of tissue/character
    • Evidence of healing (e.g., granulation tissue), or necrosis (slough or eschar)
  • Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate

If a facility has developed and implemented a protocol consistent with professional standards that addresses concerns related to maintaining resident privacy and dignity, photographs may be included to support the documentation.

Need a refresher on coding PU/PI on the MDS? CMS provides the following resource for coding information in Appendix PP: http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#TopOfPage

Next week, Mary Quinn, Clinical Consultant, will wrap up our CMSCG Blog series for pressure injuries with some helpful compliance tips and recommendations.

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