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 Injury Advisory Panel (NPIAP) Pressure Injury Staging System. The NPIAP notes that the change in terminology more accurately reflects pressure injuries to both intact and ulcerated skin. "The NPIAP is an independent not-for-profit professional organization dedicated to the prevention and management of pressure injuries. Formed in 1986, the NPIAP 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 NPIAP, 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. This information includes but is not limited to the percentage of residents with pressure ulcers. These measures are 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.
MetaStar is a Wisconsin quality improvement organization. MetaStar represents Wisconsin in the Superior Health Quality Alliance Quality Innovation Network-Quality Improvement Organization (QIN-QIO). The QIN-QIO program helps the Centers for Medicare & Medicaid Services (CMS) implement key elements of the Department of Health and Human Services' National Quality Strategy and federal health reform efforts. Superior Health members MPRO, MetaStar and Stratis Health organized as Lake Superior Quality Innovation Network work in partnership with patients, providers, and practitioners across organizations and care settings to achieve national quality goals. The Transforming Health Care Delivery report and corresponding video provide a summary of the 2014-2019 Medicare Quality Improvement Initiatives project.
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.
Wisconsin 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.
- 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 Injury Advisory Panel (NPIAP)
- 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)
- Preventing Pressure Injuries in Patients with Dark Skin
Vicky Griffin, RN, BSN, Infection Preventionist/Nurse Consultant, 414-227-4705