Non-healing Wounds

Specialties LTC Directors

Published

Help, we have a resident who is declining rapidly. She developed a stage II and within a couple of week's time it has progressed to a Stage IV! She was just put on hospice but I am concerned how to clearly document this progression effectively to show all interventions were in place to prevent the progression of the wound. She was on an air mattress, with q 2 turns, etc. My question is: When a person develops pressure ulcers, is the facility always at fault, regardless of the disease process? She refuses to eat or drink, remains in a fetal position, basically her body is shutting down. Her family is very upset with this wound and is blaming the wound for her failing health. Hospice has said this wound is non-healing. Finally, what are surveyors looking for when it comes to wounds that are facility acquired?

Specializes in ER CCU MICU SICU LTC/SNF.

http://www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf

p196

"Unavoidable" means that 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 interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.

p224

In considering the appropriateness of a facility's response to the presence, progression, or deterioration of a pressure ulcer, take into account the resident's condition, complications, time needed to determine the effectiveness of a treatment, and the facility's efforts, where possible, to remove, modify, or stabilize the risk factors and underlying causal factors.

In the same link above, read the surveyor's INVESTIGATIVE PROTOCOL pp 221-231

Criteria for Compliance pp 225-226

As far as the family..can the hospice speak with them and discuss the pressure ulcer? Sometimes hearing it from them (even if it is the same info you have been providing) the family accepts it better. Not eating, drinking, body shutting down...you can do all the interventions in the world, but that won't help.

How about the Kennedy Terminal ulcers that pop up...those are difficult to explain, but a fact.

Specializes in PICU, NICU, L&D, Public Health, Hospice.

"Kennedy" ulcers are not uncommon at end of life, particularly in the very elderly. We are often unable to slow or stop their progression as the patient continues to decline with poor nutrition, poor perfusion, and gross immobility. The hospice should most definitely be speaking with your staff and the family about these wounds. The care of the wounds will likely be directed at comfort not cure.

Sorry, I can't help you with the surveyor bit.

Specializes in Gerontology, Med surg, Home Health.

Hospice or not, have you had the tube discussion? We had a man who wouldn't eat, couldn't have a tube, was on dialysis and we still got hammered by the DPH because his would got worse. You can do everything possible and the wound still gets worse. Maybe it would help if the doc writes a note about the wound as well.

Specializes in LTC, Hospice, Case Management.
How about the Kennedy Terminal ulcers that pop up...those are difficult to explain, but a fact.

Exactly what I was thinking. Do a google search on this. I only been aware of a "term" for this in the past couple years but have seen the process many times over the years with hospice residents. Sounds a lot like what you are dealing with.

Specializes in LTC, ER, ICU, Psych, Med-surg...etc....

Just cover your bases. That way helps you to prove that the pressure ulcer is unavoiadable which sounds like what you have.

Specializes in Geriatrics, WCC.

I would also change the Q 2 hour turning. At end of life I usually have them up to every 30 min. as their circultaion si shutting down. Make sure the documentation is in order as to everything you are doing.

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