F314 – Pressure Ulcers
Long Term Care Provider
Associations Meeting
Sharon White
CMS – Region V
August 22, 2007
F314
483.25(c) Pressure Sores Regulatory Requirement:
 Based on the comprehensive Assessment of a
resident, the facility must ensure that 1) A resident who enters the facility without pressure
sores does not develop pressure sores unless the
individual’s clinical condition demonstrates that they
were unavoidable; and
 2) A resident having pressure sores receives
necessary treatment and services to promote healing,
prevent infection and prevent new sores from
developing.
Reasons to Prevent Pressure
Ulcers
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Increased morbidity and mortality
Increased infection rates
Debilitation
Pain
Increased cost
Additional medications
Increased staff time to provide
appropriate care necessary to heal
the ulcer
So what’s being done?
 National initiatives
 Advancing Excellence Campaign
 National Pressure Ulcer Advisory Panel
 GPRA
 Individual facility efforts
 CMS Regional and State Survey
Agency efforts
Provider Responsibility for
Providing Adequate Care
 Commitment to high quality pressure
ulcer management that permeates all
aspects of the facility’s operation
 Instituting a prevention program
based on accepted clinical guidelines
for “at risk” residents
 Use of Quality Measures to develop
and implement systems for pressure
ulcer reduction
Provider Responsibility for
Providing Adequate Care
 Thorough knowledge of the federal
requirements in order to comply with
the regulations and ultimately to
provide for the health and safety of
residents
 Understanding of the survey process
in helping providers evaluate the
quality of care delivered and target
quality improvement efforts
Role of RO V and the SSA in the
Reduction of Pressure Ulcers
 Investigate and evaluate the systems
and processes for prevention and
treatment of pressure ulcers in
certified facilities
 Consistent and strict enforcement of
CMS policies and regulations
An Effective “System” would
include:
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Prevention
Assessment
Identification
Intervention
Monitoring
Evaluation
Treatment
“Ownership”
Assessment
 Skin assessments are the first line of
defense to prevent pressure ulcers from
developing and to ensure effective
treatment
 It is important for clinical staff to regularly
conduct thorough skin assessments on
each resident who is at risk for developing
pressure ulcers
Assessment
 A comprehensive assessment should
address factors that have been identified as
having an impact on the development,
treatment and/or healing of pressure
ulcers, which include:
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Risk factors
Pressure points
Nutrition
Hydration
Skin moisture, and
Impact of moisture on skin
Assessment
 A comprehensive assessment should
include an evaluation of the skin
integrity and tissue tolerance after
pressure to the skin has been
reduced or redistributed
Deficiency Determination in the
Absence of Pressure Ulcers
 A facility may have non-compliance
with F314 without actual
development of pressure ulcers by
failing to:
 Accurately or consistently assess a
resident’s skin integrity
 Identify a resident at risk of developing a
pressure ulcer
 Identify and address risk factors
Deficiency Determination in the
Absence of Pressure Ulcers
 Implement preventive interventions in
accordance with the resident’s need and
current standards of practice
 Provide clinical justification for the
unavoidable development or nonhealing/delayed healing or deterioration
of a pressure ulcer
 Implement appropriate interventions for
existing wounds to minimize infection
and promote healing
Deficiency Determination in the
Absence of Pressure Ulcers
 Notify the physician of the resident’s
condition or changes in the resident’s
wound
 Adequately implement pertinent
infection management practices in
relation to wound care
 Identify and/or know how to apply
relevant policies and procedures for
pressure ulcer prevention and
treatment
Deficiency Determination –
“Avoidable vs. Unavoidable”
 Was preventive care
-aggressive?
-consistent?
-appropriate?
-resident specific?
If not, the development of a pressure ulcer
may have been “avoidable.”
Clarification “Avoidable vs. Unavoidable”
The presence of any one, or even
several, risk factors or
conditions does NOT make a
pressure ulcer “Unavoidable”
Scope and Severity
 Level 4
 Stage IV (development or non-healing)
 Stage III (infected locally/systemically)
 Extensive failure in multiple areas of care
 Level 3
 Stage III
 Recurrent or multiple Stage II’s
 Facility failure to consistently implement care
plan -> increase size, failure to heal, untreated
pain
Scope and Severity
 Level 2
 Stage I
 Stage II receiving appropriate treatment
 Failure to implement portion of care plan
independent of healing
 Level 1 – Eliminated
Region V’s Plan
 Standard surveys: Federal and state
surveyors review QM/QI Reports and CMS672 with the facility to ensure that pressure
ulcers have been reported accurately
 FOSS surveys: Federal surveyors pay
strict attention to how well SA surveyors
evaluate the nursing home’s performance
as it relates to pressure ulcers. When
identified as a concern, specific mention will
be recorded in Measures 1,2,3 and 6 of the
FOSS report.
Region V’s Plan
 Beginning calendar year 2007, Region V
is warning facilities with non-compliance
at F314, S/S level F or higher, that
continuing non-compliance will result in
the imposition of more severe remedies.
 Future cycles of non-compliance will
result in the imposition of more robust
and possibly more diverse remedies
Region V’s Plan  More severe remedies include: Optional
Denial of Payment, higher Civil Money
Penalty amounts, Directed Inservice
Training, Discretionary Termination
 Each case will be evaluated
independently to determine which
remedies will be most effective in
promoting prompt and permanent
correction of the deficiencies
Consistency is the key to
effective prevention