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June 2005

Get Up to Speed on the NEW F309/F314

The Centers for Medicare and Medicaid Services (CMS) release of the new guidance to surveyors on November 12, 2004, which entirely replaces F314 and adds definitions to F309, requires nursing home facilities to determine how these new guidelines will be implemented at the resident level.

Here are some suggestions, which may help your staff comply with the regulations:

  • Every clinical manager should receive a copy of and read the regulation (see link above), become familiar with its requirements and determine if current care and treatment of pressure ulcers needs to be adjusted/updated, etc. at the facility. Reading should also include the recognized clinical resources regarding the prevention and management of pressure ulcers listed in the regulation.
     
  • Clinical staff must be educated about these changes—nurses AND nursing assistants as well as other key team members. An in-service program should be required for all staff, and follow-up must be done at the clinical level to ensure understanding and application of the changes. Education should be ongoing for all staff, a component of orientation for new employees and a mandatory annual education requirement for all employees.
     
  • Clinical staff must know the four types of ulcers—arterial, diabetic neuropathic, pressure and venous insufficiency, and how to identify them. As a convenient reference for clinical staff, this information may be written on a small poster and displayed in a common area at the nurse’s station. Small laminated cards with the types of ulcers and how to identify them could be made for each staff member to carry in a pocket. Presenting this information one time in an in-service is not enough—the staff need reminders, “crutches”, quick references, etc. to help them become familiar with this important information.
     
  • Work with nursing staff on the importance of close visual inspection of subtle color changes on the resident’s skin upon admission and on an ongoing basis.
     
  • If your facility is not already doing so, skin assessments should be conducted at admission and then weekly for the first four weeks after admission. Because a pressure ulcer can develop in as little as two hours, you cannot assume a resident developed a pressure ulcer during a stay at a previous health care facility.
     
  • Residents must be evaluated for possible risk factors for developing pressure ulcers. Use a clinically validated risk assessment tool to identify the presence of any of the four types of ulcers.
     
  • Conduct side-by-side reviews of risk factors and care plan interventions. For every risk factor identified on the resident assessment, there should be at least one intervention to address on the plan of care.
     
  • Facilities must integrate the resident’s information, including medical assessments, lab work and pressure ulcer histories into the resident’s assessment.

All staff should be knowledgeable regarding the selection of pressure ulcer interventions. What are they? Why were they selected for this resident? Do they have a scientific basis? Treatment protocols must be based on current standards of practice. Charge nurses should conduct unit meetings with nurses and nursing assistants to discuss this information. The type of ulcer a resident has should be shared with nursing assistants on their assignment sheets as well as the intervention used.

  • DNR and other advance directives do not preclude the resident from receiving care for an existing pressure ulcer. Attempts to improve the ulcer should continue.
     
  • Repositioning intervals for residents (e.g., every 2 hours) now must be individualized according to the residents’ needs. Micro-shifting (shifting a resident’s weight off an area for 10-15 seconds) is no longer considered an intervention.
     
  • The term “decubitus ulcer” on policies and forms should be replaced with “pressure ulcer”.
     
  • Medical and nursing staff must understand how to correctly stage a pressure ulcer to prevent inconsistent assessment and documentation.
     
  • The Medical Director must be more responsive regarding pressure ulcer prevention and treatment.
     
  • Facility quality improvement programs should not only report numbers and statistics related to pressure ulcers, but must also evaluate the data and adopt a plan to assess, prevent and treat the pressure ulcer.
     
  • The interdisciplinary team must document non-pressure related wounds to minimize the likelihood of a surveyor will labeling them as
    pressure-related.
     
  • Nursing staff must be reminded to document assessments and observations of pressure ulcers adequately. At a minimum, the documentation should include:
    - Location and staging of ulcer
    - Ulcer size and presence of any sinus tracts
    - Presence of drainage—include type, color, odor and amount
    - Pain experienced by resident related to the pressure ulcer
    - Color of wound bed and type of tissue in the wound bed
    - Description of the edges of the wound bed
     
  • When a resident has an unavoidable pressure ulcer, the following information must be documented:
    - What risk factors cannot be modified
    - Why did these risk factors lead to an unavoidable pressure ulcer

Facilities need to continue to try new interventions to heal an unavoidable
pressure ulcer.

  • Staffing issues must be addressed. Would a pressure ulcer have been avoided if there had been enough staff? Staffing numbers should be based on the needs of the resident, not from a formula or by assigning equal numbers of staff on each unit.

This may be a lot of information to digest at one time. Maybe your facility has already implemented most of these guidelines. If so, you may only need to fine tune your protocols. But if you have a lot of improvements to make, forming a committee of key staff may help spread the responsibility for evaluating current practices and implementing new ones.

Educating yourself and your staff on these new guidelines must be a priority. Staff must be informed not only at the management level, but at the nursing assistant level. Educating is not to be considered the only important step—staff follow-up at the resident level must be incorporated to make certain what the staff has learned is being implemented correctly.

Sandra Kay Scott, RN, BS

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