This page is intended to provide information to assist nursing home staff to prevent and reduce the number of pressure injuries in nursing homes.
In April, 2016, the term “pressure injury” replaced “pressure ulcer” in the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Staging System. The NPUAP notes that the change in terminology more accurately reflects pressure injuries to both intact and ulcerated skin. "The NPUAP is an independent not-for-profit professional organization dedicated to the prevention and management of pressure injuries. Formed in 1986, the NPUAP Board of Directors is composed of leading experts from different health care disciplines — all of whom share a commitment to the prevention and management of pressure injuries."
According to the NPUAP, pressure injury, also known as pressure ulcer, pressure sore, decubitus ulcer or bed sore, is localized damage to the skin and underlying soft tissue usually over a bony prominence (such as the elbow, heel, hip, shoulder and back) or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful and injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear.
Pressure injuries are serious and costly medical conditions and many groups and organizations view the development of a pressure injury as one of the important measures of the quality of clinical care in nursing homes. Clinical practice, expert opinions and published literature indicates that most but not all pressure injuries are preventable and numerous guidelines exist for the prevention and treatment of pressure injuries.
Medicare.gov/Nursing Home Compare
The Medicare Nursing Home Compare website allows consumers to compare information about nursing homes. It contains quality of resident care and staffing information on every Medicare- and Medicaid-certified nursing home in the country. Nursing Home Compare also includes information about how nursing homes have performed on health and fire safety inspections.
Nursing homes routinely report clinical information about each of their residents to the Centers for Medicare & Medicaid Services (CMS). CMS uses this information to measure parts of nursing home care quality to include but limited to the percentage of residents with pressure ulcers. These measures often called “quality of resident care” and are posted on the Nursing Home Compare website. For more information visit the Nursing Home Compare Information website.
Clinical Resource Center
The Clinical Resource Center (CRC) project is jointly sponsored by the Wisconsin Department of Health Services (DHS), LeadingAge Wisconsin and the Wisconsin Health Care Association (WHCA/WiCAL), through funding from DHS. The Wisconsin Clinical Resource Center (WCRC) was originally developed in 2007 with Civil Money Penalty (CMP) funds. The WCRC was renamed to the Clinical Resource Center (CRC) at the beginning of 2016. Website development and training activities have been guided by the Advisory Group. The CRC website was designed as a user-friendly resource to provide key information to staff working in Wisconsin nursing homes about clinical care areas and training topics to include but not limited to pressure ulcer prevention and treatment.
Access to the CRC website is available to Wisconsin nursing home staff and DHS staff. It is a logon based website. If you are eligible then registering for a username and password is easy. Follow these steps.
STEP 1: Go to the CRC website.
STEP 2: Click the link that says Register.
STEP 3: Follow the prompts to sign up for an individual username and password.
For login help, contact CHSRA toll-free at 1-888-300-8098 or email the CRC helpdesk.
MetaStar is Wisconsin’s quality improvement organization and represents Wisconsin in the Lake Superior Quality Innovation Network (QIN) which is working on quality improvement in nursing homes as part of a five-year Quality Improvement Network contract with the Centers for Medicare & Medicaid Services (CMS), This contract known as the National Nursing Home Quality Care Collaborative (NNHQCC) invites all nursing homes in Michigan, Minnesota and Wisconsin to participate in this collaborative focusing on quality and performance improvement practices, increased resident satisfaction and elimination of healthcare acquired conditions to include pressure ulcers. As a representative of the Lake Superior Quality Innovation Network, MetaStar coordinates the Wisconsin Quality Coalition (WiQC), the local presence of the National Nursing Home Quality Care Collaborative (NNHQCC). Information about the WiQC and the most up to date progress in eliminating healthcare acquired conditions to include pressure ulcers in Wisconsin nursing homes is available on the Lake Superior Quality Innovation Network website.
Note: The Centers for Medicare & Medicaid Services (CMS) and the DHS, Division of Quality Assurance (DQA) acknowledges the new terminology which replaced pressure ulcer with pressure injury; however, the federal and state nursing home regulations and corresponding reports will continue to use the term pressure ulcer until such time the regulations are updated.
One of the primary ways CMS has promoted the reduction in the number of pressure injuries is through the annual survey process. Therefore, prior to each nursing home’s annual survey, state surveyors review past survey compliance information to determine:
- If the facility received a deficiency for pressure injuries.
- Whether the facility has any patterns of repeat deficiencies.
- Results of the last standard survey.
During the survey, surveyors screen all residents through observations, interviews and limited record review to identify a sample of residents who should be examined more closely. Surveyors also review pressure injury data provided by nursing homes on the Resident Census and Condition of Residents, CMS-672 form and may select residents for evaluation based on data in this report. The data includes:
- Number of residents with pressure injuries.
- Total number of residents with pressure injuries excluding stage 1 pressure injuries.
- How many residents had pressure injuries on admission.
- Number of residents receiving preventive skin care.
The survey team spends the remainder of the survey investigating all concerns including pressure injuries that require further investigation.
DQA strongly recommends that all nursing home medical directors and the QAPI (Quality Assessment Process Improvement) programs routinely monitor their pressure injury data and conduct a root-cause analysis for any resident who developed a pressure injury, had a worsening pressure injury or experienced an unplanned hospitalization related to a pressure injury. The majority of serious pressure injury deficiencies issued in Wisconsin in 2017 involved breakdowns in the care process related to:
- Failure to implement prevention measures for residents identified as being at risk of pressure injury development at admission.
- Failure to develop a resident centered-care plan based on the resident assessment.
- Failure to update the care plan and interventions based on the resident’s current needs.
- Failure to implement all care plan approaches consistently.
- Failure to monitor a resident’s skin underneath a medical device (cast, immobilizer).
- Failure to monitor the progress of the pressure injury and/or consult with the physician when indicated.
Of these serious deficiencies, 51% involved residents with diabetes, 18% involved residents with peripheral vascular disease, 16% involved residents with hemiplegia, paraplegia, or quadriplegia and 5.5% involved residents with hip fractures.
Regulations and Violations
§483.25(b) Skin Integrity -
§483.25(b)(1) Pressure Ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Wis. Admin. Code § DHS 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.
- FOCUS 2015 webcast, Dr. Joyce Black: "What is New in the 2014 Pressure Ulcer Prevention and Treatment Guidelines?"
- Institute for Healthcare Improvement (IHI) Prevent Pressure Ulcers
- National Center for Health Statistics Data Brief, No.14, February 2009 – Pressure Ulcers Among Nursing Home Residents: United States, 2004
- National Pressure Ulcer Advisory Panel (NPUAP)
- Pressure Ulcer Critical Element Pathway
- State Operations Manual, Appendix PP - refer to F686 §483.25(b) Skin Integrity
- US Department of Health and Human Services –Healthy People 2020: Understanding and Improving Health identifies the objectives of reducing the rate of pressure ulcer-related hospitalizations for older adults.
- Wound, Ostomy and Continence Nurse Society (WOCN)
Vicky Griffin, RN, BSN, Infection Preventionist/Nurse Consultant, 414-227-4705