Revised Section M of Minimum Data Set (MDS) 3.0 will change how wounds are tracked and recorded in Medicare-certified skilled nursing facilities across America.1 It is expected to be implemented on October 1, 2010. This component of the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) is radically expanded to encompass at-risk status; ulcer characteristics, including stage, size, history, and tissue type; number of ulcers; and ulcer identification.2 Standardized updated concepts of assessment and classification have been incorporated, which will require every long-term-care (LTC) facility to upgrade its training, tracking, and terminology regarding wounds.
This article educates the reader on the history of the MDS and the salient characteristics of the revised section on skin condition. The complexity of "Section M: Skin Conditions" is discussed to help assist facilities with upgrading their systems for data recording and flow. The authors also suggest considerations for making these changes. Clinicians should note that the information presented in this article was current as of March 18, 2010.
This article will help clinicians in their efforts to document accurate wound staging, classification, and measurement of wounds under the new MDS 3.0. The information provided will also help clinicians better prepare for the upcoming implementation of the revised assessment tool.
Regardless of the care setting, clinicians need to assess and record the skin condition of the individual for whom they are providing care. For example, in home care, the standardized assessment form used is called "OASIS." CMS is presently evaluating the continuity assessment record and evaluation (CARE) tool for use in the acute care setting. In LTC, the required CMS assessment instrument is the MDS, which has many sections that are designated by letters of the alphabet. Section M is about skin conditions. In the current version, MDS 2.0, it has 6 subsections, as follows:
- M1-Ulcers (due to any cause). The number of ulcers is documented, and it requires wound care clinicians (WCCs) to indicate which are Stage 1, 2, 3, or 4, regardless of ulcer etiology
- M2-Type of ulcer (2 options: either a pressure ulcer [PrU] or stasis ulcer)
- M3-History of resolved ulcer (answer either yes or no for past 90 days)
- M4-Other skin problems or lesions present (8 options for treatments that apply within the last 7 days)
- M5-Skin treatments (10 options that apply within the last 7days)
- M6-Foot problems and care (7 options that apply within the last 7 days).
The long-anticipated revision of MDS 2.0 to the next version, MDS 3.0, is on track for implementation on October 1, 2010, as indicated on the timetable posted on the CMS Web site. The current draft version of MDS 3.0 is approximately 38 pages; Section M has 11 sections and is 3 complete pages in length (Figure 1), which is significantly longer than the quarter of a page in Section M of MDS 2.0. Understanding the changes in Section M: Skin Conditions is essential for clinicians. The RAI Manual V 3.0 is a detailed, indispensable reference for accurate coding. CMS is in the process of revising the draft version of the RAI User's Manual posted Fall 2009 and, therefore, checking the CMS Web site for updated versions is warranted.
Facilities differ widely in their systems for recording wound data. For example, some LTC facilities require the charge nurse on each unit to perform measurement and recording of wounds, whereas other facilities may use a single wound-care nurse to fulfill this function. Some facilities outsource their wound care to contracted individuals or companies that identify, measure, and record this critical information. Whatever the model, the system for gathering wound-related data must be upgraded and refined in preparation for data entry into MDS 3.0.
For the purposes of simplification, the authors refer to the person collecting wound data as the WCC. Ulcer stages are designated by Arabic numerals reflecting instructions in the RAI User's Manual, in contrast to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines (http://www.npuap.org), which use Roman numerals for designation of ulcer stage.
Section M is greatly expanded in MDS 3.0, as it now has 11 subsections (Figure 1) compared with the 6 subsections in MDS 2.0. The term subsection will refer to the new M-prefixed items, such as M0100, M0150, and so on. The term lettered subsection refers to fields under each subsection. All measurements use centimeters and are measured to 1 decimal point. This article presents only the essentials of major changes and data fields in Section M of MDS 3.0, and the reader is referred to the RAI User's Manual V 3.0 for further details.
A BRIEF HISTORY OF MDS 3.0
In 1987, Congress enacted the Omnibus Budget Reconciliation Act of 1987 (OBRA'87), also called the Nursing Home Reform Amendments.3 This sweeping legislation set standards that apply to all Medicare-certified skilled nursing facilities. A central requirement of OBRA'87 was detailed resident assessment linked directly to an interprofessional, individualized treatment plan. Architects of the legislation understood that this paradigm was a central component of quality care for older adult residents.
Following passage of OBRA'87, the Department of Health and Human Services drew up the details that put this law into force. These included implementation of the RAI, consisting of 3 parts: the MDS, Resident Assessment Protocols (RAPs), and Care Plan. The purpose of the MDS was to collect a uniform data set on every resident, which would then be used to formulate the care plan, drive quality improvement efforts, and set reimbursement.
The RAI User's Manual Version 2.0 (which included MDS 2.0) was published in October 1995 and has been in use for the past 15 years. Many components of this version came under criticism. Experts argued that absence of standardized assessments and well-established clinical tools compromised relevance and reliability of MDS data.4-6 Another major criticism was inadequate attention to quality of life.7 Shortcomings of MDS 2.0 Section M included incomplete staging categories, inaccurate wound classification, and outdated assessment standards.8 For example, eschar was designated Stage 4, referencing an older system, which is no longer recommended by the NPUAP as it expanded the staging system to 6 categories (visit http://www.npuap.org for staging definitions). Wound types other than PrUs were oversimplified and used outdated nomenclature. MDS 2.0 required no wound measurements, and there was limited ability to track improved or worsened ulcers. An outdated reverse staging system was required by CMS, and there was no way to track ulcers present on admission (POA).
After development and testing for nearly 5 years, a draft version of MDS 3.0 Version 1.0 was posted on October 30, 2009, for possible implementation on October 1, 2010. It is anticipated that MDS 3.0 will address and correct technical shortcomings of the previous version and enhance its application as a reimbursement tool within the increasingly sophisticated Medicare Resource Utilization Groups (RUGs IV) system.9
HOW MDS 3.0 SECTION M CHANGES DATA COLLECTION AND CARE PLANNING
Skin assessment in LTC has now been brought more closely into line with currently recommended standards and guidelines. In addition, RAI User's Manual V 3.0 has carefully constructed rationales for each subsection creating direct links to health-related quality of life and care planning. The net result is an assessment tool that is clinically relevant and more in keeping with meeting the needs of the resident. Highlights of changes in Section M are summarized in Table 1.
MDS 3.0 presents PrU risk in a more sophisticated and clinically relevant fashion that will require collaboration with the physician or primary care provider, for example, in sections M0100, M0150, M1030, and M1040. Staging now recognizes unstageable ulcers (M0300E, F, and G) and intact skin of deep tissue injury (M0300G). The section on unhealed PrUs collects detailed information on number, stage (M0300A-G), and size of PrUs (M0610), as well as most severe tissue type (M0700), which incorporates elements from the NPUAP Pressure Ulcer Scale for Healing (PUSH) tool.
Reverse staging, also called backstaging-once the norm in tracking PrUs in LTC-is now prohibited in MDS 3.0. NPUAP has concluded that applying the staging system in reverse order is erroneous and can lead to inappropriate wound care and reimbursement.10 MDS 2.0 required reverse staging, a policy that is changed in MDS 3.0. It is no longer allowed to reverse stage PrUs. As full-thickness PrUs heal, the tissue defect is filled by scar rather than normal tissue and is therefore always at risk for further breakdown. Once an ulcer reaches a deeper level of tissue injury and thus a higher numerical stage, that ulcer remains at that stage even as it improves or heals. For example, if an ulcer reaches Stage 4 and then granulates and epithelializes, it may appear clinically shallow like a Stage 2 but is still documented as a healing Stage 4. Providers should notate all pertinent narrative information regarding ulcers in the medical record to supplement the coding information in MDS 3.0.
MDS 3.0 now allows coding for ulcers POA or reentry into the care planning system (M0300B-G). However, if an ulcer that was POA worsens in stage, it is coded at that higher stage and is no longer considered POA. (It should be noted that the term "worsens" is the language used by the CMS on the MDS form.) If a PrU is unstageable on admission and once the wound bed is visible, it can be staged (for example, a Stage 2), that ulcer is coded as POA. However, if that ulcer later evolves into a higher stage (for example, the Stage 2 ulcer just mentioned deepens into subcutaneous tissue and is now a Stage 3), it is no longer considered as POA.
Sections on worsening (M0800) and healed (M0900) ulcers provide a moving comparison of prior assessments. Because knowing the history and progression of PrUs is now part of MDS 3.0, LTC facilities will need to look at documentation processes and forms so that this information can be readily available for completion of the MDS form. Other sections include improved identification and classification for wounds other than PrUs (M1030, M1040). The treatment section (M1200), except for minor changes, is essentially the same as the old subsection M5 of MDS 2.0 subsection. The look-back period for skin condition is unchanged from previous at 7 days.
The RAI User's Manual V 3.0 no longer uses RAPs to connect MDS data to care planning. Instead of RAPs, there are Care Area Triggers (CATs) and Care Area Assessments (CAAs). MDS 3.0 is tied to care planning first through the CAT grid, which triggers each CAA. Like the prior version, the MDS is only a preliminary screen that will identify potential issues that the interdisciplinary team (IDT) will further explore. The IDT should identify current clinical protocols and resources to guide the CAA, and these resources should be identifiable on request by surveyors.
The CAA is therefore designed to expand the assessment process that begins with the MDS. One area that is beneficial from this expanded assessment is whether the ulcer was avoidable or unavoidable. MDS 3.0 Section M does not address unavoidability, but this is an important issue that most, if not all, facilities would like to incorporate. (Definitions on unavoidability can be found in the revised surveyor guidance for Tag F-314.) The CAA allows the IDT to identify specific guidelines that can be incorporated into the assessment and care planning process. As the issue of unavoidability may depend on the presence of multiple comorbidities and physiological disturbances, collaboration with the physician will be an important component of this extended assessment.11
CAAs triggered by CATs in Section M include PrUs, nutritional status, and dehydration/fluid maintenance Table 2. The CAA for PrUs is automatically triggered by any resident considered to be at risk, any stage of PrU, or any worsening ulcer.
The net result of these changes is closer linkage of the resident assessment to quality of life, incorporation of updated guidelines for ulcer staging, and broadening of the care planning process to include current clinical protocols and evidence-based standards.
PRESSURE ULCER RISK (M0100, M0150)
MDS 3.0 Section M has a PrU risk section that contains determination of PrU risk from specific clinical conditions or assessment and recognizes standardized tools. Persons are determined to be "at risk" if they meet 1 or more of 3 criteria. These include presence of PrU, "at risk" using a formal assessment instrument, or patients who are clinically assessed as being at risk. These are discussed as follows:
M0100A. Resident has a Stage 1 or greater, a scar over bony prominence, or a nonremovable dressing or device
This lettered subsection recognizes that, if a person has a PrU or a PrU that has healed, that individual is automatically classified at risk. This is true regardless of the Norton or Braden score. M0100A also recognizes that, if a patient has a nonremovable device, such as a cast or brace, an automatic at-risk score is generated.
M0100B. Formal assessment instrument/tool (eg, Braden, Norton, or other)
This lettered subsection recognizes that if a resident scores at risk using a formal tool, that individual is considered prone to developing PrUs. Formalized at-risk tools, such as the Braden Scale for Predicting Pressure Sore Risk and Norton, were not acknowledged in MDS 2.0.
M0100C. Clinical assessment
Recognition of PrU risk independent of standardized assessment tools is an important concept for clinicians to understand. Many medical factors that do not appear on the roster of entries on either the Braden or Norton Scales need consideration as contributors to PrU risk. Medications such as steroids, malnutrition, or exposure of skin to urinary or fecal incontinence can also be risk factors. A contributing factor to genesis and worsening of PrUs may be hypoperfusion of the skin, resulting from physiologic disturbances such as hypotension, severe anemia, low cardiac output, and hypoxia. Other conditions, such as end-stage renal disease, long-standing diabetes mellitus, or decreased mobility and functional ability (eg, terminal state), can also factor into clinical risk. Collaboration with the primary care physician or medical director when completing this lettered subsection will help clarify other disease-related factors leading to PrU risk.
After gathering information about a resident's PrU risk using one or all of the possible methods mentioned above, the WCC will decide if the resident is at risk for a PrU and indicate 1 for yes or 0 for no in section M0150.
UNHEALED PRESSURE ULCERS (M0210, M0300, M0610, M0700)
This group of subsections provides a detailed snapshot of the LTC resident's PrU status. To complete this section, the WCC must have a thorough knowledge of PrU staging, classification, tissue type, and measurement. Remember that staging depends on deepest visible anatomical stage, and reverse staging is prohibited. For ease of instruction, the authors grouped together subsections describing unhealed ulcers: M0210, M0300, M0610, and M0700.
M0210. Unhealed pressure ulcer(s)
This is a simple yes or no question. The WCC must know if there are any PrUs present. If the answer is yes, the WCC proceeds to the next section, M0300, for staging of the pressure ulcer(s). If the answer is no, the WCC skips to the next section, M0900, Healed Pressure Ulcers. If there are no healed PrUs, the WCC skips to M1030, Number of Venous and Arterial Ulcers. If there are no venous or arterial ulcers, Section M is complete unless the resident has other wound or skin problems (section M1040) or has skin or ulcer treatments, which is addressed in M1200.
M0300. Current number of unhealed (nonepithelialized) pressure ulcers at each stage
If the answer to M0210 is yes, the WCC must track and record in M0300 the number of ulcers with stage of each, and except for Stage 1, where the ulcers were acquired. Remember that if a POA ulcer worsens in stage, that ulcer is no longer considered POA. Throughout this section, CMS has adapted a modified version of the NPUAP staging definitions.
M0300 has 7 lettered subsections, labeled A through G. M0300A records the number of Stage 1 PrUs. There is no place on the MDS 3.0 form to document that the Stage 1 was POA. The CMS Stage 1 PrU adapted definition on this section is "intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues."
M0300B records the number of Stage 2 PrUs, and the number of Stage 2 ulcers that were present upon admission or reentry to the facility. CMS MDS 3.0 Stage 2 PrUs are defined as "partial-thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister." The WCC should note that this CMS definition differs from the NPUAP definition of Stage 2, as it includes any PrU blister regardless of type of fluid Figure 2. If POA, this is the same as the admission date. M0300B is the only section that asks for the date of genesis of the oldest Stage 2 PrU. If the date is unknown, dashes need to be put in the boxes on the form. This is the only place on MDS 3.0 where the date of genesis of the ulcer is requested, presumably because Stage 2 ulcers are expected to heal in a reasonable time frame.
M0300C and M0300D are lettered subsections for Stages 3 and 4, respectively. The WCC must know the number of ulcers for each stage and note how many were POA. Remember that, in both Stages 3 and 4, some slough may be on part of the wound bed, but it does not obscure the depth of the tissue lost. Again, if a POA ulcer worsens in stage (section M0800), it is no longer coded as POA.
There are 3 lettered subsections for unstageable ulcers: M0300E, M0300F, and M0300G (Table 3). These apply to clinical situations in which the WCC cannot visualize the wound's base. For M0300E, the wound base is covered by a nonremovable dressing or device. For M0300F, the wound base is covered by slough and/or eschar. This is a significant change in MDS 3.0 from MDS 2.0 when WCCs were instructed to document PrUs covered with slough or eschar as Stage 4. Now, these PrUs have a separate section and are documented as unstageable in the M0300F section Figure 3.
Suspected deep tissue injury (sDTI) where the skin is still intact is covered in M0300G. This section is applicable for sDTI in evolution. Unlike the NPUAP definition that includes a PrU that presents as a blood-filled blister as a sDTI, CMS instructs the WCC to document any PrU blister, regardless of what the blister is filled with, as a Stage 2 (Figure 4). WCCs need to be aware of this difference in documentation across care settings, as mandated by CMS regulations. Therefore, narrative description in the medical record is important to describe the PrU characteristics to avoid miscommunication or even misinterpretation by attorneys in the event of litigation. For each of the 3 lettered subsections for unstageable ulcers, the WCC must enter the number of ulcers present and whether they were POA.
M0610 records the size of the largest unhealed PrU from one of the following: Stage 3, 4, or unstageable ulcer. These fields require measurement of length, width, and depth in centimeters, rounded to 1 decimal point. CMS directions for PrU measurement are consistent with the recommendations of the NPUAP. Measure the longest length of the ulcer using the resident's head to toe as a point of reference. Then measure the same ulcer's widest width, side-to-side perpendicular (90° angle) to the length. Measure depth of the same ulcer by inserting a moistened cotton tip applicator into the deepest part of the ulcer and then determining the centimeters to the visible surface of the ulcer. If the largest ulcer is unstageable due to eschar or slough covering the wound bed so that depth cannot be measured, put dashes into the boxes for that dimension only. The RAI User's Manual V 3.0 contains further detailed wound measuring instructions.
M0700 records the most severe tissue type, using terminology derived from the NPUAP PUSH tool. The 4 types range from epithelial tissue (1), granulation tissue (2), and slough (3), to eschar/necrotic tissue (4). If a mixture of tissue types is present, the WCC is instructed to code for the most severe. For example, if there are both granulation tissue and eschar, the most severe tissue type is eschar, so the WCC would code a 4 in the box in this section.
CHANGES IN PRESSURE ULCER STATUS (M0800, M0900)
These 2 subsections code for changes in PrU stage (2, 3, or 4) since the previous assessment. Ulcers that were not present or were at a lesser stage on prior assessment are captured in section M0800, whereas healed PrUs are documented in section M0900. Ulcers that worsen to a more advanced stage need interdisciplinary reevaluation and care plan updating. Ulcers that heal continue to require prevention interventions because healed sites are at risk for breakdown. If this is the first MDS assessment, these subsections are left blank.
If a PrU is unstageable on admission and is then debrided to a stageable wound; it is not considered worsened. Nor is it considered a surgical wound, it is still coded as a PrU. Ulcers that occur or worsen outside the LTC facility are not captured as worsened PrUs in M0800, but rather are considered POA. If an ulcer that was POA worsens in the LTC facility, it is included as a worsened PrU in this M0800 section.
Remember that reverse staging is prohibited in MDS 3.0. For example, a Stage 4 PrU remains at this stage even until it completely heals.
OTHER ULCERS (M1030, M1040)
Completion of these subsections requires knowledge regarding differential diagnosis of ulcer types. For example, wounds of the lower extremity and foot can be secondary to arterial disease, venous disease, and/or diabetes mellitus. The authors recommend collaboration with a healthcare provider whose scope of practice includes making this diagnosis. Subsection M1030 asks for only the total number of venous and arterial ulcers present.
M1040A, infection of the foot, is the only subsection in Section M that automatically triggers the CAA for dehydration and fluid maintenance Table 2. However, remember that any resident with a skin ulcer, whether it is infected, may be at risk for dehydration. If a resident has a diabetic foot ulcer, a check mark is placed in the box at M1040B. The RAI User's Manual explains that key areas for diabetic foot ulcers are the plantar surface of the foot, especially the metatarsal heads. Ulcers caused by pressure on the heel of the foot of a resident with diabetes are not diabetic foot ulcers and should not be coded in this section. Instead, code them as PrUs under section M0300.
M1040E codes for surgical wounds, which does not include healed surgical scars, stomas, lacerations, and intravenous sites. PrUs that have been surgically debrided should not be coded as surgical wounds, but PrUs that were repaired with grafts or flaps are considered surgical wounds and must be documented in this M1040E section. The WCC will notice that skin tears are no longer included in this 1040 section of MDS3.0.
TREATMENTS IN PROGRESS (M1200)
This subsection covers general skin care including basic PrU prevention, as well as specific treatments. M1200 is almost unchanged from MDS 2.0, with the only modification in lettered subsection M1200I, which now references application of dressings to feet.
Pressure-reducing (CMS uses this term rather than redistribution) devices are listed for chair and bed, as is the turning and positioning program. Wound tracking sheets and/or care plans should give more specific information on specific devices used for prevention. Some residents cannot be turned and repositioned, and this should be addressed in the CAA and documented in the care plan. If treatments are entered into one of these lettered subsections, individualized interventions should be documented in the care plan.
HOW FACILITIES MUST ADAPT TO NEW EXPECTATIONS
Wound care is a specialized field of expertise, and the coding requirements for MDS 3.0 Section M: Skin Conditions render this field more complex. The authors recommend that personnel in LTC facilities study the RAI User's Manual, get familiar with MDS 3.0 forms, and plan implementation of changes to accommodate Section M. To keep the MDS 3.0 accurate and allow for revised and more detailed wound tracking data, skilled nursing facilities must upgrade staff education and record keeping for alterations in skin integrity. This may include training regarding risk assessment, accurate wound staging and classification (according to CMS, LTC requirements that differ in some instances from staging in other settings), and wound measurement skills. In March and April 2010, CMS held training sessions on MDS 3.0. It is expected that the slides for Section M used in these educational sessions will be available on the CMS Web site prior to the targeted Fall 2010 implementation date of MDS 3.0. CMS has also posted questions and answers from the training sessions on its Web site. Other educational materials can be found on other Web sites Table 4, but WCCs are cautioned to make sure that the staging requirements are consistent with those recommended by CMS.
The new CAA process must be anticipated prior to implementation of MDS 3.0. To accommodate the process of performing the CAA for PrUs, the facility must identify specific protocols and policies to guide decision making for PrU prevention, assessment, and treatment. Such resources can include clinical practice guidelines (for example, from NPUAP or the American Medical Directors Association), articles, guide books, and texts. These materials should be readily available to the WCC and other facility staff and utilized to guide the development of resident-specific care plans.
The medical director and physician staff must be involved in this process to ensure accuracy of data. For example, the physician can assist in clinical aspects of at-risk status for M0100C. The physician must also be involved in wound diagnosis, which reflects directly on M1030 and M1040. The physician notes must have documentation that is concordant with information entered by the WCC, as discrepancies in wound documentation have reimbursement and risk-management implications.12
Skin documentation must be prepared and placed in a format that the MDS coordinator can access easily. A review of facility procedures should also include that staff are functioning within their legal scope of practice, especially regarding assessment and diagnosis. Thus, the interface between clinical data collection through the WCC and administrative handling of the data through the MDS coordinator must be clear and well thought out in advance of the anticipated October 1, 2010, implementation date.
Clinicians need to remember that this is a "minimum" data set. The IDT must provide wound documentation in the narrative note about each PrU or other wound type. In the note, clinicians can record that a blood-filled PrU is an sDTI, even though on the MDS 3.0 it would be recorded as a stage 2 under subsection M0300B. This is because, for coding purposes, all PrUs that present as blisters, regardless of what they are filled with, are coded as a Stage 2 (Figure 4).
The fact that MDS 3.0 incorporates more current terminology and encourages the user to incorporate expanded staging categories and accurate measurement means this tool will greatly enhance communication across the continuum of care. Wounds as reflected in the nursing home record will now serve as a benchmark for other healthcare settings, such as hospitals and home care. Mandatory incorporation of risk assessment and protocols in the care planning process can result only in improved quality for all LTC residents. The authors also believe that implementation of revised Section M: Skin Conditions will necessitate empowerment of WCCs and result in further development of this very important clinical specialty.
After reading this article, the clinician will be better able to document accurate wound staging, classification, and measurement of wounds under the new MDS 3.0. The information provided will help clinicians better prepare for the upcoming implementation of the revised assessment tool. WCCs are urged to read the RAI User's Manual in its entirety, as the authors have covered only highlights of the changes.
The authors have based their comments on the determinations and information used at the CMS "Train the Trainer" sessions given in March and April 2010. Updates and addendums to the RAI User's Manual and training materials could occur, therefore WCCs should verify the currency and accuracy of information provided here by consulting the CMS Web site for official updates and changes.
1. CMS Nursing Home Quality Initiatives MDS 3.0 Overview. http://www.cms.hhs.gov/NursingHomeQualityInits/01_Overview.asp#TopOfPage
. Last accessed April 6, 2010.
2. RAI Manual Version 3.0 and MDS Forms. http://www.cms.hhs.gov/Nursinghomequalityinits/25_NHQIMDS30.asp
. Last accessed April 6, 2010.
3. Nursing Home Reform Amendments. US Code of Federal Regulations Title 42, Chapter 7, Subchapter XIX, Subpart 483.
4. Ouslander JG. The Resident Assessment Instrument (RAI): promise and pitfalls. J Am Geriatr Soc 1997;45:975-6.
5. Schnelle JF. Defining and measuring quality outcomes in long-term care [discussant]. JAMA 2007;8:E136-7.
6. Dosa D. Bowers B, Gifford DR. Critical review of resident assessment protocols. J Am Geriatr Soc 2006;54:659-66.
7. Rahman AN, Applebaum RA. The nursing home Minimum Data Set Assessment instrument: manifest functions and unintended consequences-past, present, and future. Gerontologist 2009;49:727-35.
8. Roberson S, Ayello EA, Levine JM. Clarification of pressure ulcer staging in long term care under MDS 2.0. Adv Skin Wound Care 2010;23:206-12.
9. Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2010. http://edocket.access.gpo.gov/2009/pdf/E9-18662.pdf
. Last accessed April 7, 2010.
10. National Pressure Ulcer Advisory Panel (NPUAP). NPUAP Statement on Reverse Staging of Pressure Ulcers Web site. http://www.npuap.org/archive/positn2.htm
. Last accessed April 7, 2010.
11. Levine JM, Humphrey S, Lebovits S, et al. The unavoidable pressure ulcer: a retrospective case series. JCOM 2009;16:359-63.
12. Weinberg AD, Levine JM. Clinical areas of liability in Long-term care: risk management concerns. Ann Long Term Care 2005;13:26-32.
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