Legal Issues in the Care of Pressure Ulcer Patients - Medline

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sttttttttttttsf. PhotographyKey Concept: Photography has advantages and drawbacks in terms of litigation; know theguidelines set forth by the organization.Without control, photography can be a legal detriment. The National Pressure Ulcer AdvisoryPanel (NPUAP) 27 and the Wound, Ostomy and Continence Nurses Society (WOCN) 28 neitherrecommend nor discourage the use of photography as a documentation tool for pressureulcers, in that photography poses both advantages and drawbacks. Both NPUAP and WOCNrecommend that organizations have written guidelines about if and when photography is tobe used. Such guidelines should include, but not necessarily be limited to, these points:• Obtaining informed consent• Who takes the photographs, when, and under what conditions• Type of camera equipment (digital versus other formats)• Patient identifiers• File maintenance and storage• Under what conditions and how photography is released to familiesPhoto techniques that maximize correct imaging are well covered in three recent journalarticles published in Advances in Skin and Wound Care 29, 30 and Today’s Wound Clinic. 31g. StagingKey Concept: Training in the use of NPUAP pressure ulcer staging is recommended for allhealthcare professionals, including physicians. When in doubt about a pressure ulcer’s stage,all clinicians are encouraged to “describe what they see.” Careful attention should be givento the discharge ulcer assessment.Remember that pressure ulcer assessment is more than just staging. Since staging has newbilling implications and physicians are now being held to increased accountability in thedocumentation of pressure ulcer staging in acute care facilities, a detailed discussion ofstaging is included here as part of considerations in the overall documentation process.The most commonly used system in the United States for staging pressure ulcers isthat promoted by NPUAP, 32 which was updated in February 2007. 33 Pressure ulcersare staged I to IV with two additional categories added in 2007: “unstageable” and “suspecteddeep tissue injury (sDTI).” Staging is intended to describe the depth of tissue injury at thetime the ulcer is assessed. Although the system is referred to as a “staging system,” ulcers donot progress up or down the numerical scale. This misconception of pressure ulcer progress“through the numbers” has legal implications.Revised international pressure ulcer guidelines, which are being jointly developed by NPUAPand the European Pressure Ulcer Advisory Panel (EPUAP), are expected to be released sometime during 2009.sttttttttttttsLegal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers14
sttttttttttttsCMS has classified Stage III & IV pressure ulcers as major comorbidity complications(MCC). If present on admission, these ulcers will be accounted for in the MedicareSeverity Diagnosis Related Groups (MS-DRG) adjusted payment for care. Conversely,CMS has proposed to not include Stage I, Stage II or unspecified (i.e., you did notwrite the stage), or unstageable pressure ulcers in the comorbidity/complicationclassification (CC). This means that the way in which ulcers are staged has significantimplications with regard to reimbursement in acute care and perhaps with regard to liability.Clinical documentation must be provided by the CMS-defined provider, and final staging attime of discharge is crucial for CMS billing purposes.Some staging issues to consider:• “Unstageable” ulcers are those in which the presence of necrotic material orslough prevents the assessment of the tissue base. Since Stage II ulcerations,by definition, exclude necrotic material or slough, “unstageable” ulcers mustinvolve full thickness tissue injury and will eventually be staged as either III orIV after debridement. Regardless, if the ulcer is classified as “unstageable” atthe time of hospital discharge, it will not qualify for the MCC reimbursement.• Suspected deep tissue injuries (sDTIs) often change into Stage III or IV ulcersas tissue destruction evolves and the damage that began deep within the tissueby the bone becomes visible at the skin surface and ulcerates. The definingcharacteristics, natural evolution and prevention, as well as treatment ofsuspected deep tissue injury as a pressure ulcer stage have yet to be fullydescribed and understood in the literature. 34 Should staff members modify theirinitial assessment of the appearance of the ulcer over time, perhaps revisingfrom Stage I to sDTI and then to Stage III or IV, the numeric nature of thesystem creates the impression that the ulceration is worsening, implyingnegligent care, when instead, an injury is evolving along a predictable path.• Suspected Deep Tissue injury (sDTI), although recognized in the literature, is notrecognized by CMS as a billing category. Unless the sDTI evolves and can thenbe staged as a Stage III or IV ulceration prior to discharge, the additional carerequired will not qualify the patient’s medical record for the MCC payment.• At the present time, under MDS 2.0, caregivers in long-term care are instructedto use “reverse staging” to describe healing ulcerations even though CMSacknowledges this is physiologically incorrect. Unstageable and suspected deeptissue injury cannot be used on MDS 2.0, although they may be used whencharting in the resident record. MDS 3.0, which is projected to be implementedin October 2010, is expected to remedy this problem by stating, “Do not reversestage.”sttttttttttttsliability. An obligation that may arise out of legal responsibility for an action.Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers15
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