Skin Care Policy

Skin Care Policy

Effective Date: [Original NPP Date]
Revised Date: [Current Date]

Standard:

The facility is dedicated to preventing pressure ulcers and developing risk-based prevention systems based on individualized needs and care plans. Residents receive the care and services they need according to established practice guidelines to prevent the development of pressure ulcers unless clinically unavoidable. Necessary treatment and services will be provided to promote healing, prevent infection, and prevent new pressure ulcers in residents admitted with existing ulcers.

Policy:

Residents with wounds and/or pressure ulcers and those at risk for skin breakdown are identified, assessed, and provided appropriate treatment to encourage healing and/or maintain skin integrity. Care plans are developed based on individual residents' goals and treatment wishes. Ongoing monitoring and evaluation ensure optimal resident outcomes.

Protocol:

I. Assessment: Ulcer/Risk Factors

1. On admission/readmission, assess skin integrity by completing:

   • A head-to-toe physical assessment of the skin in a manner that respects the resident’s dignity and minimizes unnecessary exposure.
   • An assessment to identify specific physical and functional risk factors associated with pressure ulcer development.

2. Following admission, assess the resident for pressure ulcer risk factors quarterly, with each comprehensive MDS and when there is a change in condition.

3. Observe the resident’s skin daily during care.

4. Pressure ulcer and non-pressure ulcer assessment includes:

   • Location
   • Measurement in centimeters (length, width, and depth, undermining, and tunneling)
   • Type of ulcer
   • Stage (if a pressure ulcer)
   • Degree of injury (if non-pressure ulcer) – partial thickness, full thickness
   • Presence of tunneling or undermining
   • Drainage amount
   • Drainage color
   • Odor (if present)
   • Appearance of wound bed tissue
   • Appearance of wound edges
   • Appearance of peri-wound area
   • Pain
   • Effectiveness of treatment

5. Assess pressure ulcers at least weekly and with significant changes until resolved.

6. If a pressure ulcer is not meeting expected outcomes, re-evaluate interventions.

II. Establishment of Treatment Goals

1. Facility staff and the resident (or the resident’s legal representative) must discuss the resident’s condition, treatment options, expected outcomes, and consequences of accepting or refusing treatment.
2. Address the resident’s concerns and offer relevant alternatives if the resident has refused specific treatments.
3. If a resident has a valid Advance Directive, the facility’s care must reflect the resident’s wishes as expressed in the Directive, in accordance with state law.
4. The presence of an Advance Directive does not absolve the facility from giving supportive and/or other pertinent care related to pressure ulcer prevention or management not prohibited by the Advance Directive.

III. Infection Control

1. Use clean technique for dressing changes; sterile technique may be ordered by the physician as indicated.
2. Use standard precautions per policy unless otherwise indicated.
3. Wound cultures are generally not indicated as most chronic ulcers are colonized and a swab culture would not provide clinically helpful information. Obtain wound cultures only when ordered by the physician.

IV. Wound Treatments

1. Wound treatments are done per MD order.
2. Stage 3 and Stage 4 pressure ulcers should be covered. Determine the need for a dressing for a Stage 1 or Stage 2 ulcer based on the individual practitioner’s clinical judgment.
3. Select products based on the relevance to the identified pressure ulcer characteristics, treatment goals, and manufacturer’s recommendations for use.

V. Avoidable/Unavoidable Pressure Ulcers

1. “Avoidable” means the resident developed a pressure ulcer and the facility did not evaluate the resident’s clinical condition and pressure ulcer risk factors, define and implement consistent interventions, monitor and evaluate the impact of the interventions, or revise the interventions as appropriate.
2. “Unavoidable” means the resident developed a pressure ulcer even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors, defined and implemented consistent interventions, monitored and evaluated the impact of the interventions, and revised the approaches as appropriate.

If the facility has implemented individualized approaches for end-of-life care in accordance with the resident’s wishes and provided appropriate efforts to stabilize the resident’s condition and prevent or treat the pressure ulcer, the development, continuation, or progression of a pressure ulcer may be consistent with regulatory requirements.

References:

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM]
• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]