In my role as a consultant and educator, I thought it would be interesting to acquire a handful of perspectives from wound care providers who work in the long-term care arena, and explore their responses.

I interviewed five experienced wound care providers starting from Columbus, Ohio and expanding to Beverly Hills, California. These particular providers work either independently, or with different wound care specialist practices. The interviews were conducted by asking each provider the same questions. Their responses reveal a number of universal issues associated with practicing wound care in long-term care settings.

What challenges do you face working in long-term care?

• Disorganization, preparedness for state surveys
• Short staff
• Staff lacking wound care experience
• Perspectives on debridement methods
• Practicing state survey dos and don'ts
• Inconsistencies with pressure ulcer staging and documentation

Working in the long-term care arena is much different than the other health care settings due to being under the microscope by the team of investigators (surveyors) that are sent by the State's Department of Health. They are sent to investigate whether the nursing home is following regulations. If the survey team finds that a regulation is not being followed within a facility, a citation is issued using an F-Tag which designates the specific regulation. F-Tag 314 refers to the regulations governing care of pressure ulcers, including prevention. The interview responses from these long-term care clinicians regarding their challenges illustrates the practical implications of regulatory compliance in working in this setting.

State surveyors are focusing more and more on "physician involvement". The previous CMS Guidelines to Surveyors were silent on the issue of physician involvement in wound care. A surveyor can now cite the facility for not notifying the physician of changes (F-157), not using correct products (F-281), not providing adequate physician supervision for wound care (F-385), and not involving the medical director in the wound care program (F-501).

Who do you normally conduct wound rounds with?

• Director of Nursing, Assistant Director of Nursing
• Unit Manager
• RN, LPN/LVN delegated that day
• Certified wound care RN or LPN/LVN
• Certified Nursing Assistant to assist in positioning

The weekly wound round's role is often times delegated to a charge nurse or unit manager. However, there are also facilities that have hired a certified wound care specialist or paid for a LPN/LVN or RN to become certified. Facilities that utilize a wound care specialist tend to have lower discrepancies during state surveys.

What type of documentation do you provide?

• Leave behind form, followed by an EMR progress note
• Progress note within 48 hours
• Dictation, followed by a progress note within 24 hours
• Documentation entered into nursing home's EMR

The wound care physician and nurse should work as a team to ensure there are no documentation discrepancies. Eliminating handwritten wound charting by utilizing wound EMR templates or apps will accurately track wound progress, thereby reducing citations. There are several software programs available for long-term care which will integrate documentation for quality reporting while at the same time increasing reimbursement.

Do you follow a specific product formulary or protocol that the facility provides?

• Product formulary is provided
• Use of a dressing category name vs. a brand name to avoid discrepancies.
• Use of products available at facility

Long-term care facilities are essentially seeking a simple algorithm. The simpler the algorithm, the more consistently it it followed. When a nurse can identify a wound type and select a dressing based on wound depth and tissue type, there are better wound healing outcomes. Nursing staff education is paramount in pressure ulcer prevention and wound healing.

Does your facility utilize you, or outside resources for wound care education?

• Mandatory in-services coordinated by nurse educator, but low attendance
• DME companies provide education as needed
• Facility utilizes online education assignments
• Wound nurse manager provides education annually

Ongoing wound care education is imperative in continuity of care. Long-term care facilities that utilize online CEUs, DME educational portals, wound care educators, and in-services will bolster quality of care. Particular wound care physician-based groups offer ways to enhance education with CEUs, free wound care certification, and/or in-services on an as-needed basis.

Utilizing a wound care physician-based group has many advantages in long-term care. Physician-based wound groups bring expertise to the patient's bedside. There is less disruption of the resident's day, along with less pain, and lower costs from transportation back and forth to the wound center. Residents also build a trusting relationship with their providers that come weekly to assess and treat their wounds. Wound rounds conducted at long-term care facilities can be a perfect opportunity for the physician and nurse to collaborate.

"Unity is strength... when there is teamwork and collaboration, wonderful things can be achieved." --Mattie Stepanek

Wound Care Specialty Physician-Based Groups
Advantage Surgical and Wound Care
AmeriWound
Skilled Wound Care
Vohra Post Acute Physicians
Coast to Coast Wound Care Surgeons

References:
The NPUAP selected "Quality of Care Regulations"

About the Author
Cheryl Carver is an independent wound educator and consultant. Carver's experience includes over a decade of hospital wound care and hyperbaric medicine. Carver single-handedly developed a comprehensive educational training manual for onboarding physicians and is the star of disease-specific educational video sessions accessible to employee providers and colleagues. Carver educates onboarding providers, in addition to bedside nurses in the numerous nursing homes across the country. Carver serves as a wound care certification committee member for the National Alliance of Wound Care and Ostomy, and is a board member of the Undersea Hyperbaric Medical Society Mid-West Chapter.