Long-Term Care Survey Alert

Published on Thu Apr 27, 2006 PDF

Follow these key clues that pressure isn't the culprit in creating a wound.

Surveyors often group all wounds into the decubiti camp, but if you follow suit, your facility will have lots of non-healing wounds--and a spotted survey record.

That's why you have to know when to suspect a wound that looks like a pressure ulcer is really a wound of a different type.
Otherwise, you'll get unfairly dinged for a pressure ulcer that all the pressure relief in the world won't heal.

Surveyors often don't have the wound care background to know when to suspect a wound isn't pressure related, cautions Peggy Dotson, RN, principal of Healthcare Reimbursement & Strategy in Yardley, PA. And even if they figure it out, you can get cited at F309 for failing to investigate the cause of a wound--especially a non-healing one.

Check Wound Location, Appearance

As part of the triage process, assess a wound's location and appearance for clues to what  caused it. "Erythema or redness over a bony prominence strongly suggests pressure ulcers," says Barbara Bates-Jensen, PhD, RN, CWOCN, at the ULCA Borun Center for Gerontological Research at the Los Angeles Jewish Home for the Aging. 
 
Venous ulcers usually occur in the so-called gater area or the inside of the leg, says Laura Bolton, PhD, a wound-care expert and researcher in Metuchen, NJ.  "But location isn't everything, as the wounds can appear on the outside of the leg," she adds.

Look for this sign: To help identify a venous ulcer, look for a brownish deposit around the wound, Bolton advises. If the patient has highly pigmented skin, look for a darker area around the wound, she adds.

When should you suspect an arterial ulcer? If the resident has poor pedal pulses and the skin looks white and pale--"almost translucent and shiny and lacks hair," advises Dotson. "Arterial ulcers are also painful," she says.

Determine Poor Circulation

Any wound or problem of the lower extremities (below the hip) requires "first and foremost" an arterial vascular assessment, recommends Michael Miller, DO. "You can use an arterial Doppler to calculate an ankle-brachial index (ABI) which compares the blood pressure in the arm to the blood pressure in the ankles," says Miller, medical director of the Wound Healing Center in Terre Haute, IN. The ABI tells you the status of the major arteries, he adds.

"If the ABI is less than 0.8 mm Hg, you'd suspect arterial involvement," says Dotson.

If you suspect an arterial ulcer in a resident with diabetes, order a transcutaneous oximetry to assess the person's microcirculation, advises Miller. "Patients with diabetes may not have significant disease of the large arteries, but their microcirculation may be very poor."

Identify Diabetic Ulcers

The revised survey guidance at F314/F309 says that for a resident to have a diabetic neuropathic ulcer, he has to have diabetes mellitus and peripheral neuropathy, notes Elizabeth Ayello, PhD, RN, APRN, BC, CWOCN, FAAN, a nursing professor at Excelsior College in Albany, NY. "The diabetic ulcer characteristically occurs on the foot, e.g., at mid-foot, at the ball of the foot over the metatarsal heads, or on the top of toes with Charcot deformity," states the survey guidance.

Clinical tip: If someone develops a wound or has poorly healing pressure ulcers of the extremities, take a look at his/her blood glucose, suggests Dotson. "The American Diabetes Association estimates that a significant number of people with type 2 diabetes are undiagnosed," she notes. "And the older someone gets, the more at risk he/she is for the condition." Also keep in mind that some of the new generation antipsychotics can drive up blood sugar, she adds.

Watch Out for Malignant, Autoimmune Wounds

Even experienced clinicians can mistake a malignant wound for a pressure ulcer or other chronic wound. Miller knows of a patient who fell down the steps and had a "mushy wound on his sacral area for eight months. Everyone assumed the wound was due to the accident. But when a surgeon excised the wound, the pathology report showed it was a basosquamous cell carcinoma."

Know when to biopsy: If a wound doesn't show progress after four to six weeks of adequate therapy, biopsy it, advises Miller. And biopsy earlier than that if a wound worsens despite adequate treatment, he adds. "You want to make sure the wound isn't malignant--or that it isn't the result of an autoimmune condition, such as vasculitis that will preclude healing. You also want a tissue culture to look for bioburden and infection," he adds.