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Clarification of Pressure Ulcer Staging in Long-term Care under MDS 2.0

Roberson, Sharon RN; Ayello, Elizabeth A. PhD, RN, ACNS-BC, CWON, ETN, MAPWCA, FAAN; Levine, Jeffrey MD, AGSF, CMD, CWS

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Advances in Skin & Wound Care: May 2010 - Volume 23 - Issue 5 - p 206-210
doi: 10.1097/01.ASW.0000363539.21070.7a
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In Brief


Clinicians in long-term care must follow the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual for pressure ulcer (PrU) staging. The manual for Minimum Data Set (MDS) 2.0 directs clinicians to stage suspected deep tissue injury (sDTI) and unstageable PrUs in a way that is different from practice in other care settings. This has led to some confusion among caregivers across the continuum of healthcare settings. It is anticipated that these differences may be corrected when MDS 3.0 is released as anticipated in the fall of 2010. This article seeks to clarify the CMS RAI Manual 2.0 regulations for PrU staging in long-term care, which clinicians must follow until MDS 3.0 is released, as well as underscore the importance of PrU care planning based on ulcer assessment.

PrUs continue to be an important healthcare concern in long-term care. The Nursing Home Reform Amendments (Omnibus Reconciliation Act of 1987) state that "Each resident must receive, and the facility must provide, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being."1 Furthermore, F-Tag 314 states that residents who enter a facility without PrUs will not develop PrUs unless the individual's clinical condition demonstrates that they were unavoidable. Because Medicare desires quality care for its 36 million recipients older than 65 years, clarification of guidance for surveyors on F-Tag 314 was revised and issued on November 12, 2004. This 40-page document, which was based on a review of the evidence available at that time, provided a succinct summary of PrU prevention and treatment.2 Despite the CMS developed educational program that was available on its Web site, some confusion about how best to document staging of PrUs on MDS 2.0 exists.

PrU staging definitions have undergone major revisions. In 2007, the National Pressure Ulcer Advisory Panel (NPUAP) added "sDTI" and "unstageable" as 2 additional stages to the original 4 stages.3,4 Most recently, on October 22, 2009, the NPUAP, in conjunction with the European Pressure Ulcer Advisory Panel (EPUAP), released new international clinical guidelines that include further revised definitions.5

Despite these updated definitions, clinicians in long-term care are bound by CMS regulations to follow the RAI Manual for MDS 2.0, which directs practitioners working in Medicare-certified skilled nursing facilities to document PrUs in some specific instances in a different way from these NPUAP-EPUAP international definitions.5 Survey compliance with MDS 2.0 requirements is mandatory. Noncompliance with MDS 2.0 requirements can result in citations of deficient practices by the regulatory agency. The penalty determination of this deficient practice depends on the scope and severity of the failure to meet the intent of the regulation, but can include monetary fines and/or closing of the long-term-care facility.

The RAI Manual is intended as an aid to gathering pertinent clinical information to be used in the development of an individualized and appropriate plan of care for the resident. Inaccurate staging of a PrU might also impact on the choice of interventions and may delay healing. Because the same PrU may be staged differently in long-term care as opposed to acute care (Figures 1 and 2), reliance on just the stage can lead to misunderstanding by clinicians and, perhaps in the case of litigation, the misinterpretation by attorney or jury that the clinician did not know how to properly stage because of the discrepancy in staging of the same ulcer in the 2 care settings. Therefore, description and documentation of the ulcer characteristics in a narrative note are essential for clinicians to be clear on what the ulcer looks like, as well as to communicate this information across care settings (Figure 3).

Figure 1
Figure 1:
STAGING A BLOOD-FILLED PRESSURE ULCER BLISTER IN LONG-TERM CARE AND ACUTE CAREIn long-term care, this blood-filled blister pressure ulcer would be documented as Stage II, whereas it would be staged as suspected deep tissue injury in an acute-care setting. Because the same ulcer would be staged differently, when persons are transferred between care settings, clinicians in both settings need to have a description of the ulcer as staging alone will be confusing due to differences in staging in the care settings.© EA Ayello, 2010.Photo is used with permission from Dot Weir, RN, CWOCN, CWS.
Figure 2
Figure 2:
HOW THE STAGING OF PRESSURE ULCERS DIFFERS IN LONG-TERM CARE AND ACUTE CAREUlcer A would be Stage IV in both long-term care and acute care. Ulcer B would also be would be documented on MDS 2.0 as Stage IV in long-term care, whereas in acute care it would be unstageable. Because of the difference in staging in each care setting, reliance on only the numerical stage could be confusing, therefore a narrative description of the ulcer including the type of tissue on the wound bed is important to communicate.© EA Ayello, 2010.
Figure 3
Figure 3:


According to the NPUAP, PrUs that obscure the wound bed with either eschar or slough so that the depth of the tissue destruction cannot be visualized would be classified as unstageable. In Medicare-certified skilled nursing facilities, current MDS 2.0 guidelines mandate categorizing this PrU as Stage IV. According to MDS coding definition, if necrotic eschar is present prohibiting accurate staging, code the ulcer/open lesion as a Stage IV (Figure 2).

This is based on instructions in the RAI User's Manual, which is echoed in F-Tag 314. These instructions must be followed for MDS coding purposes until they are revised. This raises the importance of the narrative record, which should contain descriptive elements of the wound, justify the wound categorization, and provide clarity, if and when the resident is transferred to another healthcare setting.


Current guidelines in the RAI User's Manual state that, in Medicare-certified skilled nursing facilities, a PrU that presents as a blister, regardless of fluid color, is classified as Stage II. Section M1 in version 2.0 allows for the coding of blisters if they present as a partial-thickness loss of skin (Stage II) PrU. Therefore, any PrU that presents as a blister, whether clear or blood filled, is documented on MDS 2.0 as a Stage II. Providers must continue to follow the MDS 2.0 RAI definitions for staging and coding of PrUs until the implementation of MDS 3.0.

In other settings, using the NPUAP classification system, a blood-filled PrU blister would be documented as sDTI (Figures 1 and 4). Once again, the standard of care in long-term care would dictate that clinicians describe the characteristics of PrU observed in a narrative note. This documentation can be notated anywhere in the medical record. For example, in this instance one can write, "…pressure ulcer blister is filled with sanguineous (bloody) fluid."

Figure 4
Figure 4:


The present version of the RAI (MDS 2.0 section M1) does not provide a mechanism to document purplish maroon (non-blistered) intact skin sDTI. Clinicians should refer to the RAI Manual that directs them to code, based on what is seen and not what is suspected. Facility staff can code only PrUs actually observed, based on the appearance of the area, and not what is suspected. The RAI Manual for MDS 2.0, section M, in chapter 3 (pp159-169) states: "For the MDS assessment, staging of ulcers should be coded in terms of what is seen (ie, visible tissue) during the look-back period." Until MDS 3.0 has been implemented, clinicians must follow MDS 2.0. Here, an area that is a purplish maroon intact skin sDTI should be coded in section I3 not M1, using the applicable International Classification of Diseases, Ninth Revision code. Remember that a sDTI that presents as a blood-filled blister is a Stage II on MDS 2.0 section M. Clinicians need to document somewhere in the medical record the clinical features of the sDTI area observed. For sDTI in MDS 2.0, the clarification in the medical record should also include interventions or strategies in the comprehensive care plan.


Skilled nursing facilities have been using MDS 2.0 since 1995, and experts agree that many sections need updating. To improve the reliability, accuracy, and usefulness of this tool, as well as to facilitate communication across healthcare settings, MDS 3.0 is expected to be released in the fall of 2010. Section M (skin condition) has been greatly expanded and will address many aspects of skin assessment, including ulcer dimensions and other wound characteristics, whether the ulcer was present on admission, and whether the ulcers are improving or deteriorating.6 The draft version of the RAI Manual recognizes unstageable PrUs, as well as sDTI.7 This MDS 3.0 version of the manual specifically instructs that a DTI that is a purple or maroon area of discolored intact skin should be coded as an unstageable PrU. Once again, the narrative note will clarify the clinician's direct bedside observations related to wound assessment.

The risk-management aspects of assessing for, preventing, staging, and treating PrUs have grown immensely in the last decade.8 This has resulted from a combination of several factors. First, all major organizations dedicated to advancement of healthcare quality have recognized PrUs as a quality indicator, including The Joint Commission, the Agency for Healthcare Research and Quality, and others. The immense cost of treatment of PrUs, prolonged rehabilitation, pain, and morbidity has resulted in an epidemic of litigation that targets caregivers across the continuum.9,10 The process of litigation has focused on the documentation of all aspects of PrU care, including risk assessment, prevention, staging, and treatment.11 Accurate staging has therefore increased in importance as a direct result of medical-legal scrutiny. The authors have focused on staging requirements in long-term care under MDS 2.0. An in-depth discussion of medical-legal implications of staging is beyond the scope of this article.

Advances in understanding of clinical observation and PrU pathology have expanded the staging system, leaving the MDS 2.0 with outdated terminology and classification. Individuals working in Medicare-certified skilled nursing facilities must understand this assessment tool and its limitations. Of equal importance is accurate documentation not only in long-term care, but also in the medical record that travels to other healthcare settings, such as home, rehabilitation, or acute care.12 Until MDS 3.0 comes into effect, caregivers must comprehend the MDS 2.0 limitations of its skin integrity classification system, and the best way to accomplish this is to understand both the regulations and current staging guidelines as outlined in this article.

It is important to remember that PrU assessment provides a basis for appropriate patient treatment. Data collection instruments such as the MDS 2.0 will continue to evolve and become increasingly important for data reporting, reimbursement, and determination of quality. Care planning remains an expectation with applicable interventions for the area. In addition to the regulatory requirement for use of the MDS, the development of a comprehensive care plan that is consistently implemented is also required. Providers are expected to identify and create care plans for residents who are at risk for the development of PrUs, as well as for those with existing PrUs. The interventions are to be implemented, reviewed for meeting the needs of the resident, and changed when needed.

In summary, the authors believe that dialogue and collaboration between surveyors and providers results in better outcomes for residents.


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