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
An observable, pressure-related alteration of intact skin whose indicators, as compared to an adjacent or opposite area on the body, may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the injury may appear with persistent red, blue, or purple hues.
Stage 2 Pressure Ulcer/Injury
Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.
Stage 3 Pressure Ulcer/Injury
Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.
Stage 4 Pressure Ulcer/Injury
Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Deep Tissue Injury
Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.
- "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" 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.
On the Medicare Nursing Home Compare website, anyone can compare information about nursing homes. The site posts quality of care and staffing information on every Medicare- and Medicaid-certified nursing home in the U.S. It also offers information about how nursing homes have performed on health and fire safety inspections.
Nursing homes report certain clinical information to CMS. CMS uses this data to measure aspects of nursing home care quality. CMS posts the results to help people compare and choose nursing homes. For instance, one measure reports the percentage of residents with pressure injuries/ulcers that are new or worsened. These measures often are called "quality of resident care" and are posted on the Nursing Home Compare website.
MetaStar is a health care quality improvement organization. MetaStar represents Wisconsin in the Superior Health Quality Alliance. As part of this effort, we are working with beneficiaries, communities, nursing homes, hospitals, and clinicians to advance the five goals set forth by CMS.
- Improve nursing home quality focusing on reducing unnecessary resident harm, reducing hospitalizations and increasing a facility's Five Star Quality Rating.
- Increase quality of care transitions through engagement of community coalitions to reduce unnecessary emergency department visits and increase medication safety.
- Increase chronic disease prevention and self-care for those living with cardiovascular disease, diabetes, and chronic kidney disease.
- Increase patient safety including reducing adverse drug events and healthcare-related infections.
- Improve behavioral health and opioid misuse through prevention and access to health services.
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.
- With pressure injuries that are beyond stage 1.
- Who had pressure injuries on admission.
- Who are receiving preventive skin care.
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 Assessment Process Improvement (QAPI) 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.
- Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (PDF)
- National Library of Medicine Pressure Ulcers: A Patient Safety Issue
- Federal Regulations Appendix PP (PDF) See F686 Skin Integrity
- Wisconsin Admin. Code § DHS 132.60(1)(b) Decubiti Prevention
- National Pressure Injury Advisory Panel (NPIAP)
- Preventing Pressure Injuries in Patients with Dark Skin
- U.S. Department of Health and Human Services Reduce the rate of pressure ulcer-related hospital admissions among older adults
- Wound, Ostomy and Continence Nurse Society
- The Society for Post-Acute and Long-Term Care Medicine (AMDA) (PDF)
- National Alliance of Wound Care and Ostomy
- Clinical Resource Center (CRC) Free to sign up
- Resident Assessment Manual (RAI), Appendix R (PDF)
For more information about pressure injuries in nursing homes, contact Henry Petrick, RN, nurse consultant:
- Email firstname.lastname@example.org
- Call 414-239-4857
Or Heather Newton, RN, WCC, nurse consultant:
- Email email@example.com
- Call 920-360-6102