M0300E: Unstageable Pressure Ulcers/Injuries Related to Non- removable Dressing/Device

Item Rationale

Health-related Quality of Life

Although the wound bed cannot be visualized, and hence the pressure ulcer/injury cannot be staged, the pressure ulcer/injury may affect quality of life for residents because it may limit activity and may be painful.

Planning for Care

Although the pressure ulcer/injury itself cannot be observed, the surrounding area is monitored for signs of redness, swelling, increased drainage, or tenderness to touch, and the resident is monitored for adequate pain control.

Steps for Assessment

Review the medical record for documentation of a pressure ulcer/injury covered by a non- removable dressing/device.

Determine the number of documented pressure ulcers/injuries covered by a non-removable dressing/device. Examples of non-removable dressings/devices include a dressing or an orthopedic device that is not to be removed per physician’s order, or a cast.

Identify the number of these pressure ulcers/injuries that were present on admission/entry or reentry (see page M-8 for assessment process).

Coding Instructions for M0300E M0300E1

Enter the number of pressure ulcers/injuries that are unstageable related to non- removable dressing/device.

Enter 0 if no unstageable pressure ulcers/injuries related to non-removable dressing/device are present and skip to M0300F, Unstageable – Slough and/or eschar.

M0300E2

Enter the number of these unstageable pressure ulcers/injuries related to a non- removable dressing/device that were first noted at the time of admission/entry AND—for residents who are reentering the facility after a hospital stay, that were acquired during the hospitalization (i.e., the unstageable pressure ulcer/injury related to a non-removable dressing/device was not acquired in the nursing facility prior to admission to the hospital).

Enter 0 if no unstageable pressure ulcers/injuries related to non-removable dressing/device were first noted at the time of admission/entry or reentr