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29 Thoughts to “FAQs for pressure ulcer staging”

  1. Esther Smith

    In a LTC facility, if a resident has a DTI that heals, then is hospitalized returning with an open Stage IV in the same site……is it facility or hospital acquired?? Thanks Donna

  2. Esther,
    According to the MDS 3.0 RAI manual, If a current pressure ulcer worsens to a higher stage during a hospitalization, it is coded at the higher stage upon reentry and should be coded as “present on admission” or hospital acquired.

  3. Denise Dauzat

    If a patient enters an Ltac with pressure ulcer scars and while in the Ltac the scars reopen,is this considered a new hospital acquired or a deterioration of a wound?

    1. Donna Sardina

      Denise,
      I am not familiar with the most current regulations for LTAC’s, however, I recommend checking with either your facility policies or LTAC guidelines for the answer.

  4. Jacqueline Rufo

    1) Is there granulation on stage II pressure ulcer?

    2) Pateint has DTI on R heel and is positive for DVT after doppler study… is that a pressure ulcer or venous ulcer?

  5. Brenda, PR

    If a pressure ulcer develops granulated tissue in the center, resulting in the division of the ulcer in two, should it be counted as two different ulcers, or it still being counted as the same ulcer?

  6. michelle skaggs

    In reference to the last question, isnt slough dead subcutaneous tissue? If so that would not be present in a partial thickness wound, would it? if there is slough wouldn’t that automatically make the wound full thickness?

  7. ES

    A PATIENT CAME TO OUR FACILITY WITH STAGE 4 DECUB ON SACRUM EXTENDING TO R AND L BUTTOCKS,AFTER 4 -5 MONTHS THEY WERE ALL HEALED,ALL DECUB HEALED IN FEB OF 2013 FAMILY WAS SO HAPPY,THERE WAS A PRESSURE REDUCING DEVICE IN PLACE ,SKIN CHECK WEEKLY,CNA CHECK ON SHOWER DAYS ALL LOGGED,TURNED AS FREQUENTLY AS POSSIBLE, THIS PATIENT IS TOTAL CARE WITH CONTRACTURES IN ALL EXTREMITIES CONNECTED TO A VENTILATOR,LAST SEPT. WE HAD A SURVEY,ONE OF THE SURVEYOR FOUND A 0.4-0.5CM OPEN WHERE THE OLD SCARRING OF THE PREVIOUS HEALED STAGE 4,APPEARED JUST HAPPENED AT THAT TIME,TX NURSE WAS VERY SURE IT WAS NOT THERE THE DAY BEFORE,THE SURVEYOR CHECKED AROUND 10AM,NO WT LOSS,PT HYDRATED ON GT.,DX ANEMIA,CKD.IS IT CONSIDER UNAVOIDABLE?IF SO WHAT APPROPRIATE GRADE IN TERMS OF THE SCOPE OF SEVERITY.

  8. george

    hi, if a pt had a stage 4 and he got a surgical flap and healed. And then a sore develops on that same spot would it be considered a reopened stage 4 or a new stage 2 if the opening is superficial, or a reopened surgical wound? please help

  9. Sherry

    If resident comes into facility with a stage II that she has had at home for years, we heal it in facility and after about a month it re-opens, is that a facility acquired or community? Is there a time frame for it to be still the community acquired verses facility?

    1. Donna Sardina

      Sherry,
      You probably will not like this answer but once the pressure ulcer is healed and then reopens while living in the facility, it would be considered a facility acquired pressure ulcer.

      Definition of a healed pressure ulcer according to CMS RAI Manual for Long Term care: Completely closed, fully epithelialized, covered completely with epithelial tissue, or resurfaced with new skin, even if the area continues to have some surface discoloration.

  10. tam

    Hi. I am new to a LTC facility and need to know where I can find some of the state and CMS guidelines for these types of facilities, regarding wound care and required documentation. Is it different from the hospital setting? That’s what I have observed so far, but want to make sure I’m doing the right thing.

  11. Donna Sardina

    Tam,
    Documentation guidelines vary based upon care settings and governing bodies. Below are some links to different guidelines for Long Term Care. In addition, be sure to check your facility policies for documentation guidelines as some Long Term Care facilities document above and beyond the Federal requirements.
    Wishing you the best in your new position!
    CMS Guidance to Surveyors: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

    CMS Survey Process for Skilled Nursing Facilities: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c07.pdf
    Section M in the MDS 3.0 RAI Manual http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-3-0-RAI-Manual-v1_11-and-Change-Tables_October-25-2013-R-.zip

  12. AL

    Can a closed water blister turned into eschar after using betadine as treatment ?At first we stage that as stage 2 since it was not open but after using betadine there is eschar noted which is unstageable so how can we describe that in notes that it changed from stg2 , to unstageable.can u please comment on this situation

  13. sahily

    A patient has a pressure ulcer which has part of the wound bed covered with eschar. If the nurse can distinguish some muscle, tendon or bone on the part of the ulcer that IS observable, can it be staged as a stage IV pressure ulcer? Thanks a lot!

    1. Donna Sardina

      Sahily,
      You are correct. PU staging is based upon the deepest tissue injury/destruction through the layers of the skin either visible or directly palpable. The deepest a pressure ulcer will be is when there is visible: bone, tendon/ligament or muscle, which is a Stage IV.

  14. Galit Tessler

    if a patient has a stage 1 to heel and it has not healed for over 2 month, despite treatment and pressure off loading, now has a more purple like discolor, can we stage it as a SDTI?

    1. Donna Sardina

      Galit,
      If the area meets the following description then it should be staged as an sDTI. “Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

  15. Marie

    If a patient has a documented abrasion to the left hip, but a wound care doctor is performing surgical debridement would it be classified as an abrasion or now a surgical wound?

    1. Donna Sardina

      Marie,
      Debridement is a treatment procedure applied to the abrasion, so therefore it remains an abrasion. Another thought, if the abrasion has developed slough & necrotic tissue related to pressure, then it should be reclassified and staged as a pressure ulcer.

  16. Elvia

    If a patient came in with a healing stage IV and now has slough covering 100% of wound bed, is now classified as unstageable? or that will be considered back staging

  17. Donna Sardina

    Elvia,

    It would still be considered a Stage IV, even though slough has covered it, giving it the appearance of unstageable. The category of unstageable was developed to represent a pressure ulcer that the true depth is unknown because the base is covered and muscle bone or tendon are not seen or palpable. However since the true depth is known, in this case, it can not get any worse than a Stage IV and can not be downstaged to a stage III. As the saying goes, once a stage IV, always a stage IV.

  18. Teresa

    The question: “A patient’s waistband dug into his side and caused skin breakdown. Is this considered a pressure ulcer?” has an incorrect answer.

    This would not be considered a pressure ulcer. A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. This is an abrasion, not a pressure ulcer.

  19. Amanda

    If you have a med/surg pt come to your hospital with a stage I wound and then gets worse would you restage the wound. Example went from a stageI to a stageII and treatment was changed to relfect the new wound. The only time that you don’t restage is if the wound was a stage IV and starts healing you wouldn’t chart it as a stage III?

  20. Abi

    How long does it take for a blanching buttock to worsen to stage III or necrotic?

  21. Cassidy

    If a wound that is unstageable is eventually debrided of eschar, does it continue to be unstageable or can it now be staged to current status?

  22. Theresa M. Campbell

    I would like to clarify something please. I am an MDS nurse at a LTC/Rehab facility. We had a patient admitted with a large unstageable pressure ulcer with slough according to our wound nurse. In 14 days she is now stating that it healed in the center and now there are three pressure ulcers (2 with slough and 1 with epitherlial). Am I correct to think it should still be the unstageable that it started with but make a note that it is healing? Is it correct to say that it is healing with slough under it? We have been having trouble with our wound nurse documentations and I dont think she is using any resource to help with questions because she answers with “I think”. Thank you for your help.

  23. Vina Gilbert

    If a pressure injury completely heals, should the parameter/documentation be discontinued? What happens if it reopens? Especially if it was a healed stage 4 pressure injury that is already prone to skin damage due to previous damage? Would that still be considered hospital acquired?

    1. Vina Gilbert

      Also, could you provide literature that supports what is the standard to documenting on healed pressure injuries?

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