It has been a long week. The CMS state survey team entered your facility Sunday afternoon at 2pm. Thursday is finally here and the state survey exit meeting is only minutes away. Your heart is heavy and your mind is occupied with thoughts of an in-house acquired, stage IV pressure ulcer. The surveyor observed your dressing change and reviewed every bit of documentation pertaining to this stage IV pressure ulcer. The burning in your gut has completely convinced your brain that your facility will receive the dreaded F-Tag 314 because of this in-house acquired pressure ulcer.

Suddenly, the exit meeting is complete. It is a few moments before you realize you never heard the only words you were listening for: wound care… in-house acquired… stage IV pressure ulcer… F-Tag 314.

Slightly bewildered and mostly exhilarated, you clock out after your fifth 14-hour workday this week. You cannot stop wondering how you "lucked out" and avoided getting an F-Tag 314.

The reality of how you avoided the F-Tag 314 can be found in the details of your wound documentation. Let's review the wording of the F-Tag 314 and discuss the actions and documentation that helped you to avoid it.

Information and definitions regarding the F-Tag 314 can be found in the State Operations Manual, Appendix PP – Guidance to Surveyors for Long Term Care Facilities. The State Operations Manual Guidelines are taken from the Code of Federal Regulations Title 42, developed by the federal government.

CFR-2015 Title 42 volume 5 section 483-25 reads:

(c) Pressure sores. 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.

Pressure Ulcer Risk Assessment

Documentation of your resident's Braden score is part of the comprehensive assessment CMS surveyors want to see. The Braden score assessment should be completed upon admission, quarterly, and any time your resident experiences significant change in condition.

Resident's Braden scale assessment score of 12 indicates high risk for developing a pressure ulcer. This nurse observed no open areas to be noted at this time, "R" to be monitored closely for signs of skin breakdown.

Identifying your resident as high risk is not the only part of your documentation that prevented the F-Tag 314. You also documented the clinical conditions that put your resident at risk for developing a pressure ulcer.

"R" has contractures bilateral lower extremities, causing the knees to press together. "R" is unable to comply with nutrition, dx of cachexia. "R" has advanced dementia, at times combative during care and repositioning.

Once you identified the risks and clinical conditions, you put interventions in place to prevent your resident from developing a pressure ulcer.

This nurse implemented offloading with a pillow placed between the knees, will continue to turn and reposition as tolerated. Foam wedge in place for side-to-side positioning. "R" to be evaluated by PT for wheelchair positioning due to complaints of pain associated with current wheelchair. "R" is now on a low air loss, alternating pressure mattress due to refusing to get out of bed.

Documenting Pressure Ulcer Prevention and Treatment Interventions

The State Operations Manual, Guidance to Surveyors for Long Term Care Facilities tells surveyors to look for documentation that shows the use of "routine and individualized interventions" The documentation of your on-going management of the in-house acquired pressure ulcer is crucial. Weekly measurements, assessments of how the wound is responding to treatments, and documentation of new interventions when current interventions become ineffective are all parts of proper wound management.

Treatment for stage IV PU of the sacrum done. "R" tolerated well, wound edges macerated, skin protectant to peri-wound added to current treatment order for calcium alginate packing, also frequency changed to daily. Depth measures 0.3cm less this week.

So how did you avoid getting the F-Tag 314 even though you had a resident with an in-house acquired stage IV pressure ulcer?

State surveyors determined the stage IV pressure ulcer to be unavoidable due to the resident being high risk and having contributing clinical conditions based on your documentation. Although it is unfortunate when a resident in long-term care develops a pressure ulcer, it is not always avoidable. The most important thing you can do for your resident when this happens on your watch is to provide quality care and interventions specific to this resident. The most important thing you can do for yourself and your facility when this happens is document the quality care and interventions you provided.

Not only did your documentation show the stage IV pressure ulcer was unavoidable, but your documentation also showed that you did something about it. More importantly, you continued to do something about it. This is how you avoided the dreaded F-Tag 314. Great job!

About the Author
Terri Kolenich, RN, CWCA, AAPWCA is the clinical liaison at Select Medical Specialty Hospitals. Terri has extensive experience in long term care as a Wound Care Nurse and Program Manager. She is passionate about wound care education and has over nine years experience assessing, managing, and documenting wounds. Terri is also well versed in MDS 3.0. Her knowledge coupled with her skill as a public speaker, make her an effective wound care educator.