F686 Skin Integrity: The “New F314”

In November 2017 CMS implemented new guidance to surveyors for long-term care facilities. Facilities are expected to review and integrate these new standards into care. The interpretive guidelines refer to the categories of care as “Ftags. ” The interpretive guidelines can be used by Plaintiff and Defense attorneys working on cases focused on long-term care matters. The expert in medical record review in long-term care litigation, ALN Consulting, helps clients by breaking down the new information on CMS guidance to surveyors in our educational video series. Understanding these intricacies gives our clients the upper hand.

F686: Treatment & Services to Prevent & Heal Pressure Ulcers

F686, “Treatment/Services to Prevent/Heal Pressure Ulcers” was referenced in the old guidance as “F314.” The CFR regulations pertaining to this Ftag are §483.25 (b)(1)(i)(ii). The new guidance incorporates the most current and correct term, “pressure injuries (PI’s),” and notes that facilities may use the terms pressure ulcer (PU), pressure injury, pressure sore, decubitus ulcer, and bed sore to describe alterations in skin integrity due to pressure in the medical record. The guidelines also note that CMS “often refers to the National Pressure Ulcer Advisory Panel’s (NPUAP) terms and definitions” and intends to “continue our adaptation of NPUAP terminology for coding the resident assessment instrument while retaining current holistic assessment instructions definitions and terminology.” The new guidance also included updated and detailed descriptions of how pressure injuries should be “staged” in medical records to indicate the characteristics and extent of tissue injury, including in the MDS assessment tool.

The update to the F686 interpretive guidelines for prevention of pressure injuries includes:

• Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter;
• Evaluate resident specific risk factors and changes in the resident’s condition that may impact the development and/or healing of a PU/PI;
• Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; and
• If a PU/PI is present, provide treatment to heal it and prevent the development of additional PU/PI’s.

Unavoidable Pressure Injuries

New guidance addresses unavoidable pressure injuries and includes a statement on risk factors, that “not all risk factors are fully modifiable or can be completely addressed. Some risk factors, such as a permanent lack of sensation in an area, may not be modifiable. Some potentially modifiable risk factors, such as malnutrition or uncontrolled blood sugars, may take time to correct, despite prompt intervention.” Other risk factors, described in detail, such as pressure are noted to be potentially modified promptly.

F686 includes updated guidance on pressure points, tissue tolerance, nutrition/hydration, moisture, prevention and treatment strategies, resident choices, repositioning, support surfaces and pressure redistribution, and monitoring. The addition of a detailed description of The Kennedy Terminal Ulcer (KTU) is new to the guidance. These pressure injuries are an unavoidable part of the dying process, also known as “skin failure.” The facility is responsible for accurately assessing and classifying an ulcer as a KTU or other type of PU/PI, and record what preventative measures were in place to prevent non-KTU pressure ulcers.

Key Interventions for Healing Pressure Injuries

Importantly, the new F686 guidance includes specific interventions for healing pressure injuries, including advice that residents with PU/PI’s on the sacrum/coccyx or ischia should limit sitting to three times a day in periods of 60 minutes or less, and residents with an ischia injury should not be seated in a fully erect posture in chair or bed.

Key Elements of Noncompliance

Surveyors of long-term care facilities will use the interpretive guidelines to cite deficient practice regarding F686 if the investigation shows the facility failed to do one or more of the following:

• Provide preventative care, consistent with professional standards of practice, to residents who may be at risk for development of pressure injuries; or
• Provide treatment, consistent with professional standards of practice, to an existing pressure injury; or
• Ensure that a resident did not develop an avoidable PU/PI.

ALN Consulting retains expert nurse reviewers who know the CMS interpretive guidelines inside and out, enabling them to impact their client’s outcomes at every turn. ALN reviewers understand new regulatory and compliance guidelines in long-term care so that every case has the most informed opinion of liability. Contact us today to review your long-term care, medical malpractice, or wrongful death case.