Wound care therapies continue to advance, but even with these advances, pressure wounds/injuries are a focus of the Centers for Medicare & Medicaid Services and comprise a significant percentage of claims in long-term care settings.  Accurate documentation is essential in confirming a precise diagnosis, demonstrating quality wound care, receiving appropriate reimbursement, complying with regulations, and defending claims and litigation.

National wound care expert, Martha Kelso, and healthcare defense attorney LaDonna Boeckman provided an overview of the new wound care regulations and the potential impact on defending wound cases at the recent DRI Senior Living and Long-Term Care Seminar.  This informative presentation reinforced the need for accurate diagnosis and detailed documentation, noting that “misdiagnosing a pressure wound is surprisingly frequent, often with legal ramifications.”

Diagnosing Wounds

CMS states “It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound.”  A pressure wound/injury, also referred to as a bedsore or decubitus ulcer, is localized damage to the skin and/or underlying soft tissue due to prolonged pressure, or a combination of pressure and shear, over a bony prominence.  A staging system classifies pressure wounds to describe the depth of tissue destruction.  Further, wounds are termed “avoidable” or “unavoidable” based on whether specific processes were followed, not as a medical question.  Techniques for managing pressure injuries include proper repositioning every two hours, protective padding, proper hygiene, moisture reduction, use of air mattresses/pressure relief devices, frequent skin assessments, and adequate nutrition.  Treatment options continue to advance, and include dressings, debridement of necrotic tissue, laser sessions, ultrasound, cellular tissue-based products, recombinant platelet-derived growth factors, and hyperbaric oxygen.

However, not all skin wounds are pressure wounds/injuries.  Skin wound/failure can also be related to conditions including, but not limited to:

End-of-life skin changes require specific documentation.  For example, Kennedy Terminal Ulcers (KTU) can be differentiated from pressure ulcers/injuries in that:

• Appear suddenly and within hours
• Usually appear on the sacrum and coccyx, but can appear on the heels, posterior calf muscles, arms, and elbows
• Edges are usually irregular and are red, yellow, and black as the ulcer progresses
• Shaped as a pear, butterfly, or horseshoe
• Often appear as an abrasion, blister, or darkened area and may develop rapidly to Stage 2, Stage 3, or Stage 4 injury.

Hypoperfusion or compromised perfusion associated with organ failure due to the dying process is the origin of the KTU and other end-of-life skin changes such as a Kennedy Lesion, mottling, Trombley-Brennan Terminal Tissue Injury, Skin Changes at Life’s End (SCALE) wounds, open fungating wounds, and open malignant wounds.  These types of skin failure at end-of-life are unavoidable symptoms for some dying patients.

Ms. Kelso emphasized that care of wounds due to hypoperfusion focuses on interventions that support comfort such as decreased turning, repositioning, and reduced dressing changes, rather than resolution, as in pressure wound treatment.  Strategies for optimizing end-of-life wound care include educating staff, setting expectations with family members, and managing symptoms to improve patient care and quality of life and mitigate regulatory or legal issues.  Quality medical record documentation is the underlying theme in these strategies to ensure effective communications on the palliative nature of end-of-life care.

CMS Regulations

CMS Minimum Data Set changes in October 2023 issued new guidance on coding skin changes not caused by pressure.  These wounds should not be coded in Section M[i] Skin Conditions of the MDS.  Under the new Section GG: Functional Abilities and Goals, CMS will begin public reporting through Care Compare of the percentage of high-risk residents with pressure ulcers in January 2025.  Of note, diagnostic codes for reimbursement purposes do not coincide with the new regulatory changes for end-of-life skin or wound changes.  The presenters stressed the importance of staff training and documentation to protect against claims of failure to assess correctly and the defense of the wound caused by end-of-life and not by pressure.

Claims and Litigation

According to the MarshMcLennan Oliver Wyman 2024 General and Professional Liability Benchmark Report for Senior Living and Long-Term Care Providers, skin/wound injury and infection are the second leading cause of loss behind falls.  In large loss claims (greater than $1 million) in long-term care, 13.1% are due to infection and 10.1% are skin/wound injury.  The analysis of the claims descriptions reveals the following data on Skin/Wound Injury and Infections:

The CNA Aging Services Claim Report: 11^th Edition showed the average total incurred for pressure injury-related allegations in assisted living has increased by more than 67% (to $282,358) from 2018-2021 and surpassed the skilled nursing average of $252,520.  Skilled nursing facilities account for 94.7% of pressure injury closed claims, and 2/3 of pressure injury claims in AL and SNF resulted in death.  CNA notes a “review of the resident healthcare information record often reveals that the defensibility of claims is impeded by the lack of adherence to a facility’s own policies and procedures.”  Documentation is a key element of risk management, including, but not limited to:

• Skin evaluations on admission, readmission, and changes in condition
• Referral to appropriate wound specialists
• Evaluation of wound and interventions
• Documentation by contract providers
• Changes in condition/appropriateness of level of care
• Staff education on pressure injuries
• Communication with family on resident condition/expectations

Documentation Reviews to Support Care, Compliance and Claims

Excelas partners with senior living providers, insurers, and defense counsel in the defense of wound cases.  Our experienced medical analysts review medical and other pertinent records and develop reports to support decision-making which frequently include:

• Turning and Repositioning Chart – a simple, visual layout to demonstrate the consistency of care given to a resident.
• Care Calendar – an interactive calendar to visualize the date and time of all interactions with a resident.
• Medical Chronology – a customizable report of the resident’s care which can be easily sorted by topic, record type, or provider of care.
• Case Summary – a high-level summary of the medical history including an opinion by our medical-legal analysts on whether the records support or refute the allegations and comments on any additional areas for investigation
• All reports include hyperlinks to the page(s) in the medical record where the care is documented.

Each of these work products are used to assess the quality of medical record documentation, provide ongoing training for staff on documentation improvement, prepare for audits, demonstrate compliance with current regulations, evaluate the merits of a claim/case, and assist counsel in developing defense strategies.  Contact Excelas today for a demonstration of our software and analytic tools and reports.