Last year, the Centers for Medicare & Medicaid Services (CMS) released the long-awaited revision of Pressure Sores Tag F-314. This revised guidance to surveyors is part of the State Operations Provider Certification, which impacts 13,000 skilled nursing facilities throughout the country.
The revised guidance document contains a wealth of information for health care providers, including definitions, assessment and treatment risk factors, nutrition interventions, and advance directives. According to this document, the admission assessment is an essential part of a program to prevent and treat pressure ulcers. In the area of nutrition, risk factors for pressure ulcers include undernutrition, malnutrition, and hydration deficits.
Weight loss and protein energy malnutrition in older adults have been associated with an increase in mortality.1–3 In studies conducted in long-term-care facilities, the prevalence of malnutrition ranged from 23% to 85%.4 Cognitive impairment is another factor that may contribute to nutritional deficits.
Regardless of the resident's initial pressure ulcer risk score, health care providers (including a member of the nutrition team) should review the risk factors and the potential causes individually5 to:
- identify risk factors that increase the potential for the development of pressure ulcers
- decide which risk factors can be modified, stabilized, or removed
- determine which protocols should be implemented to reduce the patient's risk.
The following case study demonstrates the role of a nutrition assessment and appropriate interventions in helping a facility achieve compliance with Tag F-314.
An 88-year-old woman is admitted to a skilled nursing facility for care following a hip fracture. She has been diagnosed with dementia, anemia, and hypertension. On admission, she is incontinent and edentulous, and is confined to a wheelchair except during physical therapy.
The resident is 62 inches tall and weighs 105 pounds. She consumes only about half of a regular diet and drinks only 2 cups of fluid daily. Her Braden Scale risk assessment score on admission is 13 and her nutrition score is 1. The goal of the nutritional assessment is to avoid weight loss by providing 6 small meals a day.
Two weeks later, the resident has developed a Stage II pressure ulcer on her coccyx. Nursing measures to treat the pressure ulcer are initiated. No changes are made in her nutritional care plan. The resident continues to receive 6 meals, which she rarely eats. There is no evaluation of her dental status or her ability to chew the meat. The food intake records indicate that no substitutes were offered for foods that she refused nor were any supplements offered.
Her nutritional status is not monitored, however. She is still eating poorly, rarely consuming meat or other foods rich in protein. Within 30 days, the pressure ulcer has progressed to Stage IV and the resident has lost 6% of her body weight, which has not been reported to her physician, family, or dietitian.
At this point, state surveyors select the resident's chart for review. The survey team completes its investigation of Tag F-314, analyzes the data, reviews the regulatory requirements, and identifies the deficient practices. They subsequently cite the facility for failing to comply with the requirements of Tag F-314: failure to identify factors that placed the resident at risk for pressure ulcers, failure to implement interventions, and failure to revise the approach to care as appropriate for this resident. The surveyors also cite Tag F-325 Nutrition and F-327 Hydration. Tag F-325 Nutrition states that based on the resident's comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as body weight. The surveyors determined that the weight loss was unplanned, the resident refused food and staff failed to offer her alternate items, and her oral health status was poor. Her individual care plan goals were not periodically evaluated, nor were alternative approaches considered. Tag F-327 Hydration states that the facility must ensure sufficient fluid intake by each resident to maintain proper hydration and health. The facility failed to identify the factors that placed her at risk for dehydration, and failed to assist or cue the resident to drink or offer alternative approaches to increase fluid intake.
What Went Wrong?
A much different outcome would have resulted if the staff, including the dietitian, had followed an appropriate clinical path and initiated interventions to prevent the pressure ulcer from developing or to heal it before it reached a Stage IV.
On admission, the resident was found to be undernourished and edentulous and to have a hydration deficit. The staff should have identified her food preferences and served her favorites to stimulate eating and deal with her nourishment issues. Because she was edentulous, the staff should have:
- determined if the consistency of her diet needed to be changed and requested a speech evaluation
- offered snacks between meals
- checked whether she needed assistance at mealtime
- weighed her weekly and recorded the weights in her chart.
To manage the resident's hydration deficit, the staff should have offered her fluids between meals and during daily care and encouraged her family to get involved in mealtime.
Pressure Ulcer Interventions
Two weeks after admission, the patient developed a Stage II pressure ulcer. At this point, appropriate interventions should have included:
- a dietary consultation with the staff and caregivers
- documentation of a revised care plan, including a request for routine comprehensive metabolic panel to evaluate her biochemical data, increased protein intake (1.2 to 1.5 gm/kg body weight), and a request for the physician to order a multivitamin
- review of the resident's medications to determine if any were causing adverse reactions that could affect her appetite
- consideration of fortified foods.
At 30 days, the resident had a Stage IV pressure ulcer and significant unintentional weight loss. Interventions to promote healing and restore the lost weight should have included:
- notification of the family, physician, and dietitian that the resident had lost too much weight
- evaluation of the resident's food and fluid intake by the dietitian and recommendations for improving her intake
- encouragement of an exercise program that would stimulate her appetite
- evaluation of her need for assistance with feeding
- implementation of a restorative dining program, which is free from distractions and interruptions. The caregivers focus on frequent reminders to eat or drink, and offer alternative forms of food, such as finger foods or popsicles.
- request for inclusion of wound-specific supplements, for example, supplements fortified with L-arginine, glutamine, ascorbic acid, zinc, and vitamin E.
- review of the resident's advance directive as it relates to nutrition
- consideration of other treatment options, such as palliative care.
The Path Not Taken
Unfortunately, this clinical path was not followed. The staff did not appropriately assess and document the resident's nutritional status, and her condition deteriorated. Frequent evaluation and revision of the plan would have helped improve the outcome.
In addition, the resident had progressive dementia and was unable to ingest adequate calories, an expected outcome of the disease. That should have been taken into account when developing her care plan. Nutrition interventions should have been geared toward maximizing calorie intake, with appropriate revisions to the plan as the resident's condition changed.
This case history illustrates how nutrition plays a key role in helping a facility achieve compliance with Tag F-314. It also demonstrates the importance of nutrition and hydration in preventing and healing pressure ulcers to improve outcomes of care.
1. Liu L, Bopp MM, Roberson PK, Sullivan DH. Undernutrition and risk of mortality in elderly patients within 1 year of hospital discharge. J Gerontol A Biol Sci Med Sci 2002;57:m741–m746.
2. Sullivan DH, Walls RC. Protein-energy undernutrition and the risk of mortality within six years of hospital discharge. J Am Coll Nutr 1998;17:571–8.
3. Thomas DR, Verdery RB, Gardner L, Kant A, Lindsay J. A prospective study of outcome from protein-energy malnutrition in nursing home residents. JPEN J Parenter Enteral Nutr 1991;15:400–4.
4. Abbasi AA, Rudman D. Undernutrition in the nursing home: prevalence, consequences, causes and prevention. Nutr Rev 1994;52:113–22.
5. Ayello EA, Baranoski S, Lyder CH, Cuddigan J. Pressure ulcers. In: Baranoski S, Ayello EA, editors. Wound Care Essentials: Practice Principles. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.