Nursing Homes – Pressure Injury (Pressure Ulcer) Information

This web 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."

Background Information

Data from the most current 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.

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 ulcers.

Medicare.gov/Nursing Home Compare

The Medicare Nursing Home Compare website allows consumers to compare information about nursing homes. It contains quality of care information on every Medicare- and Medicaid-certified nursing home in the country. Nursing Home Compare includes comprehensive information on 5-star quality ratings of overall and individual star performance on health inspections, hours of care provided per resident by staff performing nursing care tasks, and quality measures. The set of quality measures that describe the quality of care in nursing homes includes a number of clinical areas including % of residents with pressure sores. For more information visit the Medicare Nursing Home Compare quality measure information web pages.

Clinical Resource Center

The Clinical Resource Center (CRC) 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. 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.

REGISTER

Access to the CRC website is available to Wisconsin nursing home staff and the Wisconsin Department of Health Services (DHS). It is a logon based website. If you are eligible then registering for a username and password is easy, and here is all the information you need to know.

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

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.

Survey Process

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 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 (QM) Report to determine if the nursing home's pressure ulcer percentile rank is 75 or above. The survey team must select this area for review for any nursing home whose percentile rank is above this threshold. Should a facility’s pressure ulcer percentile rank be under 75, the survey team must still pick a sample of residents with pressure ulcers for review and determine if they received appropriate care to prevent and or treat these pressure ulcer(s).

The DQA strongly recommends that all nursing homes routinely monitor their Quality Measure Reports with their medical director and quality assurance committee to determine if their percentile rank is at or above the thresholds for pressure ulcers. As the majority of serious deficiencies issued in 2016 for pressure ulcers were related to breakdowns in the care process related to:

  • Failure to implement prevention measures for residents identified as being at risk of pressure ulcer development at admission.
  • Failure to develop a care plan based on the assessment.
  • Failure to update the care plan and interventions based on the residents current needs.
  • Failure to monitor a resident’s skin underneath a medical device (cast, immobilizer).
  • Failure to monitor the progress of the pressure ulcer and consult with the physician when indicated.

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 or had a pressure ulcer and experienced an unplanned hospitalization.

Regulations and Violations

Federal Regulations

§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.

State Violations

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.

Additional Resources

DQA Contacts

Vicky Griffin, RN, BSN, Infection Preventionist/Nurse Consultant, 414-227-4705

Lindsay Buttles, RN, MSN, Nurse Consultant, 920-360-0445

Last Revised: February 16, 2017