Nursing Homes: Pressure Ulcer/Injury Information

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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. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft tissue.

Note: CMS is aware of the array of terms used to describe alterations in skin integrity due to pressure. Some of these terms include pressure ulcer, pressure injury, pressure sore, decubitus ulcer and bed sore. Clinicians may use and the medical record may reflect any of these terms, if the primary cause of the skin alteration is related to pressure. For example, the medical record could reflect the presence of a Stage 2 pressure injury, while the same area would be coded as a Stage 2 pressure ulcer on the MDS.

CMS often refers to the National Pressure Ulcer Advisory Panel's (NPUAP) terms and definitions, which it has adapted, within its patient and resident assessment instruments and corresponding assessment manuals, which includes the Minimum Data Set (MDS). We intend to continue our adaptation of NPUAP terminology for coding the resident assessment instrument while retaining current holistic assessment instructions definitions and terminology.

In April 2016, the term "pressure injury" replaced "pressure ulcer" in the National Pressure Injury Advisory Panel (NPIAP).

Stage 1 Pressure Ulcer/Injury

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. Color changes of intact skin may also indicate a deep tissue PI.

Stage 2 Pressure Ulcer/Injury

Partial-thickness loss of skin 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. This stage 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/Injury

Full-thickness loss of skin, 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/Injury

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/Injury

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.

Deep Tissue Injury

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. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

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. The injury should be staged using the staging system.

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.

Friction/Shearing

"Friction" is the mechanical force exerted on skin that is dragged across any surface.
"Shearing" occurs when layers of skin rub against each other or when the skin remains stationary, and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage.

Avoidable/Unavoidable

"Avoidable" means that the resident developed a pressure ulcer/injury, and that the facility did not 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, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.
"Unavoidable" means that the resident developed a pressure ulcer/injury even though the facility had evaluated the resident's clinical condition and risk factors; defined and implemented interventions that are consistent with resident needs, goals, and professional standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.

Note: the above definitions were taken from the most current State Operations Manual, Appendix PP.

One way CMS aims to reduce pressure injuries is through the annual survey process. Before each nursing home's annual survey, state surveyors review past survey information to find out:

Whether the nursing home received a deficiency for pressure injuries.
Whether there is a pattern of repeat deficiencies.
Results of the last standard survey.

During the survey, surveyors observe and interview residents and review records to find a sample of residents to assess more closely.

Surveyors also review data on the Matrix for Providers, CMS-802 (PDF) form or the individualized facility assessment. They may select residents to assess more closely based on data in this report. The data includes the number of residents:

With pressure injuries.
Who acquired pressure injuries after admission.
What interventions were in place.

The team spends the rest of the survey investigating any concerns about pressure injuries.

DQA strongly recommends that all nursing home medical directors and Quality Assurance and Process Improvement programs monitor their pressure injury data. A root-cause analysis should be conducted for any resident who:

Developed a pressure injury.
Had a worsening pressure injury.
Had an unplanned hospital stay related to a pressure injury.

Pressure Ulcer/Injury Critical Element Pathway is used for a resident having, or at risk of developing, a pressure ulcer/injury to determine if facility practices are in place to identify, evaluate, and intervene to prevent and/or heal pressure ulcers/injuries. All critical element pathways can be accessed on CMS Survey Resources (ZIP).

Contact us

For more information about pressure injuries in nursing homes, contact Heather Newton, RN, WCC, nurse consultant:

Email heathera.newton@dhs.wisconsin.gov
Call 920-360-6102