Column 2 is completed at the OASIS follow-up and discharge time points. When there are one or more pressure ulcers listed in a row of Column 1, the same row of Column 2 will be completed answering this question "How many of the ulcers listed in the same row of Column 1 were also present at the most recent of SOC/ROC?" It is irrelevant if the ulcer(s) represented in Column 1 was the same or a different stage at the SOC or ROC. What is relevant is the history of the ulcer(s) in the same row of Column 1. A pressure ulcer that was present at SOC/ROC that has either deteriorated or improved is still the "same" pressure ulcer and is not a "new" ulcer. If a row in Column 1 is "0," then the same row in Column 2 must also be "0." If the number of ulcers reported in Column 1 is greater than in Column 2, it indicates new pressure ulcer(s) developed since the SOC or ROC (CMS, 2011). See the sidebar for tips on completing M1308s.
M1320: The Status of the Most Problematic (Observable) Pressure Ulcer
All pressure ulcers except Stage I are considered in this item. Refer to Figures 1–3, 5, and 6. To identify the status or degree of closure visible in the most problematic observable pressure ulcer (CMS, 2011) requires the ability to identify tissue types and structures observed at the time of wound assessment, knowledge of and correct application of the WOCN Guidance on OASIS-C Integumentary Items document (WOCN, 2009), and critical thinking.
For example, a female patient is incontinent of urine and stool and has a Stage II pressure ulcer on the coccyx that is being treated with a hydrocolloid. Like the other dressings that the spouse said were used before, the hydrocolloid is not adhering and requires several changes in a day. The patient also has a Stage IV pressure ulcer on the right trochanter being treated effectively with Negative Pressure Wound Therapy (NPWT). In this case, although the ulcer on the coccyx is a lower stage, it may be the most problematic because it is more difficult to manage.
The healing status of an unstageable pressure ulcer except for one under a nonremovable dressing or device (M1308 d.1) can be identified. Following the WOCN Guidance on OASIS-C Integumentary Items, a pressure ulcer with more than 25% avascular tissue is statused as not healing (WOCN, 2009). A suspected deep tissue injury (DTI) (M1308 d.3) is not covered with new epithelial tissue and granulation tissue is not visible; therefore, the most appropriate status is "not healing" (CMS, 2011).
Accuracy when "statusing" wounds is important. This item affects the agency's Outcome-Based Quality Monitoring Program Carefully monitoring the healing status of wounds will reduce emergent care for wound infections, deteriorating wound status, which is also a Potentially Avoidable Event (CMS, 2010b).
M1324: Stage of the Most Problematic Unhealed (Observable) Pressure Ulcer
The stage of a pressure ulcer is based on the NPUAP (2007) updated staging system (http://www.npuap.org/pr2.htm), which identifies the definitions for each stage of the pressure ulcer. Stages I to IV pressure ulcers and closed Stages III and IV pressure ulcers are unhealed and can be observed/visualized. As the wound base of a pressure ulcer reported in M1308 d.1, d.2, and d.3 cannot be observed or visualized, it is "unstageable" and the correct response selection is "NA: No observable pressure ulcer or unhealed pressure ulcer." As the focus of this item is identifying the stage of a pressure ulcer, when there are both stageable and unstageable pressure ulcers present, the clinician will consider the stageable ulcer as the most problematic when completing M1324. Unstageable pressure ulcers are considered the most problematic when they are the only type present.
The POC synopsis as a process measure captures best practice and identifies if the HHA plans to include evidence-based clinical actions in the POC/485 that promote good patient outcomes. A best practice is reported when the clinician collaborates with the physician regarding assessment findings and plans for care, which result in a verbal or written order within the OASIS-C assessment time frame (within 5 days after the SOC and 2 days of the ROC) that becomes a part of the POC/485 (CMS, 2011). Examples of such "best practices" are establishing specific parameters to report changes in the patient's condition, foot care monitoring and education on proper foot care to patients with diabetes, specific interventions for prevention of pressure ulcers, treatment of pressure ulcers, and so on (CMS, 2011). Refer to Appendix for POC Synopsis M 2250.
Select "Yes" when verbal or written orders for the specific plans/interventions are received from the physician within the OASIS-C assessment time frame and subsequently included in the POC. Select "na" if the criterion in the "not applicable" column is met. Select "No" when you cannot select "Yes" or "na"; that is when the best-practice intervention from Column I is not included in the POC, or a physician's order for the best-practice intervention was not obtained or was not discussed and confirmed with the physician before including the order on the POC/485. Also select "No" when the orders were requested from the physician but not received within the assessment time frame (CMS, 2011). Documentation of the rationale for any "no" response is expected in the clinical record.
A "No" answer does not indicate best practice; therefore, it is important that the clinician select responses for M2250 considering if the item applies to that particular patient. If it does not, select "na"; if it is applicable, select "Yes" or "No," depending on whether orders for the best-practice interventions have been obtained and received. For example, an HHA patient with a Braden Score of 22 is not assessed to be at risk for the development of pressure ulcer based on the scoring mechanism of the tool; therefore, interventions to prevent pressure ulcers are not warranted. The clinician may be inclined to select "No" for M2250f because it appears as a first choice. However, when there are no physician orders obtained for the POC to reduce the risk of pressure ulcers, the correct response is "na" because the assessment indicated the patient was not at risk. Conducting an assessment to determine the patient is not at risk is an appropriate clinical action and also a best practice.
M2400 Intervention Synopsis
This item is also used to capture the HHA's use of best practices during the quality episode; it identifies if the POC included specific interventions and if these interventions were implemented by any agency clinician at the time of or since the previous OASIS-C assessment. "It is anticipated that processes of care implemented according to evidence-based guidelines will ultimately lead to better clinical outcomes" (CMS, OASIS-C Guidance Manual, 2011). Refer to Appendix, POC Synopsis M2400.
As with M2250 POC Synopsis, best practice is identified with "Yes" and "na" responses. Select "Yes" when the intervention is included in the physician ordered POC and implemented at the time of or since the previous OASIS assessment (CMS, 2011). Select "na" when the conditions in the "not applicable" column are met. When the intervention is appropriate for the patient, select "No" when you cannot select "Yes" or "na," that is if at the time of or since the previous OASIS assessment, the intervention was ordered and not implemented, or if the intervention was implemented but not ordered. Documentation of the rationale for any "no" response is expected in the clinical record.
OASIS data are used to produce quality reports for agencies and for public reporting on the Medicare Home Health Compare Web site, as well as to determine payment. "In any data-driven system, the quality of the output is only as good as the quality of the data input" (CMS, 2011). It was found that for the clinician to answer the integumentary M items accurately, they had to be knowledgeable in wound assessment and wound healing physiology, which was reviewed in Part I of this two-part article. In Part II, the focus was on the M items with clarifications about some terms and concepts that cause the staff to struggle. For years, HHAs were held accountable for not showing improvement in patients' outcomes when they had very little—if any—control on variables that can interfere with the achievement of these outcomes. Some of these variables can include the challenges of the patient's or caregiver's willingness or ability to adhere to the POC, obtaining approval from the insurance or healthcare provider for the need for DME items such as mattress support surfaces that would aid in reducing risk for pressure ulcer development and also the impact of comorbid conditions and clinical circumstances in which a pressure ulcer may be unavoidable (Wound, Ostomy and Continence Nurses Society Position Statement on Avoidable Versus Unavoidable Pressure Ulcers, 2009).
OASIS-C introduces process measures that are based on "best practices" aimed at promoting good outcomes. HHAs are not required to adopt these process measures at this time, but there is evidence that incorporating them in practice will lead to improvement in patient outcomes (CMS, 2010a).
The use of wound photographs with each of the M items was a successful technique employed to help clinicians "see what we were saying" and to use as a reference when reflecting on the critical questions developed to guide the assessment of the patient's wound. Clinicians are urged to remain abreast of changes in the OASIS-C guidance, which is frequently updated.
Questions and answers to OASIS-C questions are published quarterly on the CMS Web site https://www.qtso.com/hhadownload.html (QIES Technical Support office, OASIS Download, n.d.).
The authors acknowledge and thank Rhonda Will, RN, BS, COS-C, HCS-D, assistant director, OASIS Competency Institute, Fazzi Associates, and the many contributors at the Visiting Nurse Service of New York whose comprehensive and coordinated work on OASIS-C made this wound care education initiative possible.
Tips on Completing M1308
- Perform a thorough skin assessment on all patients.
- Do not just ask if there is a pressure ulcer—SEE FOR YOURSELF!
- Inquire about all scars, especially the ones on/near bony prominences or suspected to be pressure-related.
- Complete the assessment within the allotted time period for reporting OASIS data (within 5 days after the SOC or 2 days of the ROC) (CMS, 2011), and on a day that the wound is to be assessed.
- Document all closed Stages III and IV pressure ulcers.
- Enter "0" if there are no pressure ulcers at that stage.
- At follow-up and discharge from the agency:
- First complete Column 1.
- If Column 1 is "0," Column 2 must also be "0."
- If there is a wound in Column 1:
- Find out if it was present at SOC/ROC or the date it developed.
- Include the ulcer in the "count" for the same row of Column 2 if the ulcer was present at SOC or ROC.
- A pressure ulcer that was present at SOC or ROC that has either deteriorated or improved is still the "same" pressure ulcer; it is not a new ulcer. For example, a Stage II ulcer on the sacrum at SOC that has deteriorated to a Stage IV at Follow-up (recertification) will be reported on OASIS-C M 1308 as in Table 1 and 2.
Note. OASIS = Outcome and Assessment Information Set; ROC = resumption of care; SOC = start of care.
from Centers for Medicare and Medicaid Services. (2010a, March). OASIS PBQI/process measures
from Centers for Medicare and Medicaid Services. (2010b). Outcome-based qualitymonitoring (OBQM) manual
from Centers for Medicare and Medicaid Services, OASIS-C Guidance Manual (2011, January). Retrieved
from European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. (2009). Pressure ulcer prevention quick reference guide
from National Pressure Ulcer Advisory Panel. (2007). Updated staging system, pressure ulcer stages revised by NPUAP
from QIES Technical Support Office, OASIS Download. (n.d.) CMS Q & A
. Retrieved (find Wound Ostomy Continence Nurse Society. (2009).
© 2011 Lippincott Williams & Wilkins, Inc.
Wound, Ostomy and Continence Nurses Society Position Statement on Avoidable Versus Unavoidable Pressure Ulcers. (2009, July/August). Journal of WOCN