Ftag of the Week – F686 Treatment/Svcs to Prevent/Heal Pressure Injuries (Pt. 1)

For our next “Ftag of the Week” on the CMSCG Blog, we will be delving into the extensive requirements related to the prevention and treatment of pressure injuries.

Pressure injuries pose a significant risk to residents – as well as providers – so for this Ftag series, CMSCG Consultant Mary Quinn, RN, BSN, MA will be lending her clinical expertise to cover this topic.

F686 – The Regulation

The regulatory requirement for F686 states that a facility is required to ensure that residents receive care to prevent pressure ulcers and do not develop pressure ulcers unless their clinical condition demonstrates that they were unavoidable. Additionally, for residents with pressure ulcers, the facility must provide the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. The intent of this requirement is to ensure, to the extent possible, that residents do not develop pressure ulcers/injuries unless they are clinically unavoidable, and that staff provide appropriate care and services to prevent injuries, promote healing and/or prevent the development of additional issues.


Per the Interpretive Guidance (IG), the Centers for Medicare & Medicaid Services (CMS) notes that alterations in skin integrity related to pressure are described using many varying terms i.e., pressure injury, pressure ulcer, decubitus ulcer, bedsore. The medical record may reflect any of these terms but CMS in its guidance, refers to the National Pressure Ulcer Advisory Panel’s terms and definitions. Regardless of the staging system or wound definitions used by the facility, the facility is responsible for completing the MDS utilizing the staging guidelines found in the RAI Manual.

While the SOM has a comprehensive list of definitions which can be referenced, let’s review and highlight some of the primary terms.

“Pressure Ulcer/Injury (PU/PI)” refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.

“Avoidable” means that the resident developed a pressure ulcer/injury, and that staff failed to do one or more of the following:

  • Evaluate the resident’s clinical condition and risk factors;
  • Define and implement interventions that are consistent with resident needs and goals, and follow professional standards of practice;
  • Monitor and evaluate the impact of the interventions; or
  • Revise interventions as appropriate

“Unavoidable” means that the resident developed a PU/PI even though the facility had provided necessary care and services (as listed in the bullets of the prior definition).

Looking for all the definitions included with this regulatory requirement? View this document.

Staging-Related Terms

There are also additional key terms related to staging, so these are important definitions to be familiar with. Responsible staff need to know the difference between the following so they can appropriately stage and document pressure injuries per these guidelines:

Stage 1 Pressure Injury:
  • Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness).
  • In darker skin tones, the PI may appear with persistent red, blue, or purple hues.
  • The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes.
 Stage 2 Pressure Ulcer:
  • Partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer.
  • The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister.
  • Adipose (fat) is not visible and deeper tissues are not visible.
  • Granulation tissue, slough and eschar are not present.
  • Stage 2 should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions).
Stage 3 Pressure Ulcer:
  • Full-thickness skin loss, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present.
  • Slough and/or eschar may be visible but does not obscure the depth of tissue loss.
  • The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds.
  • Undermining and tunneling may occur.
  • Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed.
  • If slough or eschar obscures the wound bed, it is an unstageable* PU/PI.
Stage 4 Pressure Ulcer:
  • Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer.
  • Slough and/or eschar may be visible on some parts of the wound bed.
  • Epibole (rolled edges), undermining and/or tunneling often occur.
  • Depth varies by anatomical location.
  • If slough or eschar obscures the wound bed, it is an unstageable* PU/PI.
*Unstageable Pressure Ulcer:
  • Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar.
  • Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident’s physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws.
  • If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed.
  • If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur.
Other Staging Considerations
Deep Tissue Pressure Injury (DTPI):
  • Persistent non-blanchable deep red, maroon or purple discoloration
  • Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin.
  • This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.
  • The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss.
  • If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer.
  • Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. 
Medical Device Related Pressure Ulcer/Injury:
  • Medical device related PU/PIs result from the use of devices designed and applied for diagnostic or therapeutic purposes.
  • The resultant pressure injury generally conforms to the pattern or shape of the device.
Mucosal Membrane Pressure Ulcer/Injury:
  • Mucosal membrane PU/PIs are found on mucous membranes with a history of a medical device in use at the location of the injury.
  • Due to the anatomy of the tissue, these ulcers cannot be staged.

So now that you have the terms and definitions, where do you go from here? Let’s begin with what happens on admission or readmission.


When a resident is admitted to your facility, it is imperative that as part of the comprehensive resident assessment, a thorough skin inspection/evaluation is conducted and documented. Any skin concerns that are identified as “present on admission” should have a treatment order as indicated and baseline and/or comprehensive care planning initiated.

A review of transfer paperwork should always be conducted. Many times, admission assessment findings are not consistent with documentation received from transferring facilities.  If the transferring paperwork does document skin issues, each area of concern should be addressed.

If the initial admission evaluation doesn’t include etiology/staging, a staff member “competent” in the identification of classification of wounds/staging of pressure injuries should re-assess the skin and complete any necessary clarifications on a timely basis. i.e., weekly wound rounds are not the appropriate venue for admission clarification, if conducted days after admission. 

Communication with the resident representative should include the presence of any wounds. They are not always aware of the presence of wounds prior to admission and may assume they developed at your facility.

In Part 2 of our “Ftag of the Week” series for F686, we’ll look at the requirements for assessment and prevention.

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