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Nursing Homes  - Pressure Ulcer Information

This web page is intended to provide information to assist nursing home staff to prevent and reduce the number of pressure ulcers in nursing homes. 

Background Information

Data from the 2004 National Nursing Home Survey was published in the February 2009 National Center for Health Statistics Data Brief. This data brief presents the most recent national estimates of pressure ulcer prevalence, resident characteristics associated with pressure ulcers, and the use of wound care services in U.S. nursing homes.  Key findings include: 

  • In 2004, more (11%) than 1 in 10 nursing home residents had pressure ulcers. Stage 2 pressure ulcers were the most common. 
  • Residents aged 64 years and under were more likely than older residents to have pressure ulcers. 
  • Residents of nursing homes with a length of stay for a year or less were more likely to have pressure ulcers than those with longer stays. 
  • One in five nursing home residents with a recent weight loss had pressure ulcers. 
  • Thirty-five percent of nursing home residents with stage 2 or higher (more severe) pressure ulcers received special wound care services in 2004.

Pressure ulcers, also known as bed sores, pressure sores, or decubitus ulcers, are wounds caused by unrelieved pressure on the skin. They usually develop over bony prominences, such as the elbow, heel, hip, shoulder, and back. Pressure ulcers are serious medical conditions and one of the important measures of the quality of clinical care in nursing homes. Pressure ulcers are preventable and numerous guidelines exist for the prevention and treatment of pressure ulcers.

Wisconsin Clinical Resource Center

The Wisconsin Clinical Resource Center (WCRC) project is jointly sponsored by the Department of Health Services, LeadingAge Wisconsin and the Wisconsin Health Care Association (WHCA/WiCAL), through funding from the Wisconsin Department of Health Services. Development support is provided by staff from the Center for Health Systems Research & Analysis (CHSRA), University of Wisconsin-Madison. The WCRC website was designed as a user-friendly resource to provide key information to staff working in Wisconsin nursing homes about selected care areas and training topics.

REGISTER now for Individual Log-ins!! Current log-in procedures are changing to allow individual nursing home staff to access the website. Previous facility passwords will no longer be available after October 15, so spread the word about these changes! Here is all the information you need to know to ensure that you and your nursing home continue to have access to the WCRC resources:

STEP 1: Go to the WCRC Website Address: https://wcrc.chsra.wisc.edu (exit DHS)

STEP 2: Click the link that says “Register”.

STEP 3: Follow the prompts to sign up for an individual logon.

For more information - contact your nursing home association, WCRC email: wcrc@chsra.wisc.edu, WCRC Helpdesk: 888-300-8098.

Wisconsin Pressure Ulcer Coalition

The Wisconsin Pressure Ulcer Coalition (WPUC) was formed in December 2007 and is comprised of several Wisconsin stakeholder groups including the Division of Quality Assurance, Wisconsin Homes and Services for the Aging, Wisconsin Health Care Association, Wisconsin Hospital Association, Rural Wisconsin Health Cooperative Health Initiative, MetaStar, and representatives from nursing homes, home health, hospice and assisted living. The primary mission of the WPUC is to reduce the incidence and prevalence of pressure ulcers using proven strategies.

In the fall of 2008, the WPUC invited hospitals, nursing homes, assisted living, home health, and hospice providers to participate in a one year collaborative improvement project that emphasizes the use of evidence based guidelines to prevent pressure ulcers. The project began in early December with the first training session held on January 15th, 2009 in Wisconsin Dells. The project is modeled after the very successful New Jersey Pressure Ulcer Collaborative that significantly reduced pressure ulcers across the continuum of care.

Participating organizations were expected to develop a team and be actively involved in the improvement methodologies. The project consists of two in-person learning sessions, teleconferences, monthly data submission and ad hoc support. Individualized reports are provided that highlight improvements made in reducing pressure ulcers within each organization. The project emphasizes the importance of working across the care continuum by partnering nursing homes, hospitals and providers from other care settings with each other so that communication and problem solving occur.

The WPUC is currently in the process of recruiting nursing homes for year two. For more information about the WPUC, contact Jody Rothe RN, WCC at (608) 441-8271 or via email at jrothe@metastar.com

CMS GPRA Goal

The Centers for Medicare & Medicaid Services' (CMS) two Government Performance Results Act (GPRA) goals for nursing homes include reducing the number of pressure ulcers in nursing homes. These goals were first articulated in CMS Survey & Certification (S&C) Letter number 05-01 (exit DHS), titled Guidance on Working with Quality Improvement Organizations. 

In July 2006, CMS Region 5 provided the DQA with regional GPRA goals for pressure ulcers and restraints. The CMS Regional GPRA goal for pressure ulcers was set at 7.4%. 

Every quarter, the DQA monitors the progress of Wisconsin nursing homes in achieving the GPRA goals. Wisconsin's average percentage of pressure ulcers is 7.0% based on first quarter 2009 data. You may view the progress of pressure ulcer reduction in Wisconsin nursing homes at the following links:

Percent of Residents with Pressure Ulcers - 1st Quarter 2009 (PDF, 190 KB)

Percent of Residents with Pressure Ulcers - 4th Quarter 2008 (PDF, 190 KB)

Survey Process

One of the primary ways that CMS has promoted the reduction in the number of pressure ulcers is through the annual survey process.  State and CMS surveyors who conduct annual inspections of nursing homes will focus on these areas during every annual survey.

Therefore, prior to each nursing home's annual survey, state surveyors review each nursing home's Quality Measure/Quality Indicator (QM/QI) Reports to determine if the nursing home's "observed percent" of pressure ulcers is 7.4% or above. The survey team must select this area for review for any nursing home whose "observed percent" is at or above this threshold.

  • Nursing home staff may use CASPER via their access to the State MDS System to generate and retrieve QM/QI reports for their facility. 

  • The Medicare Nursing Home Compare website (exit DHS) uses a Five Star Quality Rating System to compare nursing homes.  The Quality Measure domain includes the percent of high-risk long-stay residents who have pressure sores and the percent of short-say residents with pressure sores as two of the ten QMs that are used in the rating methodology.

  • Nursing Home QI/QM User Manual is available on the Downloads area of the CMS Nursing Home Quality Initiatives website (exit DHS).

The DQA strongly recommends that all nursing homes routinely monitor their Quality Measure/Quality Indicator Reports with their medical director and quality assurance committee to determine if their "observed percent" is at or above the thresholds for pressure ulcers.  As the majority of serious deficiencies issued in 2008 and 2009 for pressure ulcers were related to breakdowns in the care process related to lack of timely assessment, care planning, consistent implementation of the care plan and reevaluation of the care plan.  The medical director and quality assurance committee should also review on a monthly basis the number of pressure ulcers that are present on admission versus facility acquired pressure ulcers.  A root-cause analysis should be completed for any resident who developed a facility acquired pressure ulcer.

Regulations and Violations

Federal Regulation - §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

State Code - 132.60(1)(b) - Decubiti Prevention.  
Nursing personnel shall employ appropriate nursing management techniques to promote the maintenance of skin integrity and to prevent development of decubiti (bedsores).  These techniques may include periodic position change, massage therapy and regular monitoring of skin integrity.

132. 60(1)(b) Nursing Home Violations by Class and Year (PDF, 15 KB)

Civil Money Penalties and Forfeitures

Nursing homes may be assessed Civil Money Penalties (CMPs) for federal citations and/or Forfeitures for state citations.  Listed below are statistics related to CMPs and Forfeitures for citations issued related to pressure ulcers.

 

# Assessed

$ Assessed

CY 2009 (as of 9/1/09)
   F314
   132. 60(a)(b)

  2     
77     

   $11,4750
$2,885,897
CY 2008
   F314
   132. 60(a)(b)

  7     
63     

     $18,400
$1,781,143
     

Additional Resources

DQA Contacts

Vicky Griffin, RN, BSN, Nurse Consultant
(414) 227-4705

 

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Last Updated: November 20, 2013