OASIS Alert

Wounds continue to be a sore spot for home health agencies when it comes to OASIS.

If your clinicians aren't careful, the way they respond to questions like MO450 could make your agency look like it's falling down on the job when your next adverse event report comes around. That's because if you don't answer the questions addressing wounds correctly, your patients could end up appearing to have an increase in the number of pressure ulcers under your care, experts warn.

"If at the start of care I don't identify that the patient has a pressure ulcer, but at discharge someone else identifies that he does, it would look like [the patient] developed it during the home care plan," notes consultant Linda Krulish, president of Home Therapy Services in Redmond, WA.

Some agencies run into trouble when the patient has an unobservable pressure ulcer (due to a nonremovable dressing, for example) at the start of care. In this case, the clinician doesn't stage that wound, because obviously she can't stage something she can't see. However, in some cases the nurse will stage the wound on a subsequent assessment after the dressing has been removed. If this situation isn't handled properly from day one, it looks like the patient's pressure ulcer count has increased, warns consultant Patti Johnston, president of Positive Outcomes in The Woodlands, TX.

To avoid this problem, the clinician should mark 'Yes' on MO440 ("Does this patient have a skin lesion or an open wound?") and MO445 ("Does this patient have a pressure ulcer?"), Johnston says. When the clinician gets to MO450 ("Current number of pressure ulcers at each stage"), she should choose '0' for the number of pressure ulcers at stages one through four, assuming the unobservable wound is the only one present. (If the patient has multiple wounds, the clinician should stage those she can see.)

Then, mark 'Yes' on part E of MO445 ("In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including casts?"), Johnston instructs.

"By doing this, you are responding that you have a pressure ulcer and it can't be staged," Johnston tells Eli. Using this process, as long as the patient doesn't develop any more pressure ulcers, she won't appear to have gained any, she says. Following this process on the initial assessment makes it clear that the patient still has the same wound, "the difference is now it can be staged."

Another way HHAs can wind up with black marks on adverse event reports when they actually should get gold stars is when clinicians goof on healing wounds, says Chapel Hill, NC-based consultant Judy Adams with the Larson Allen Health Group. This problem occurs when the patient has, for example, one large wound at admission, and the wound begins to heal during the plan of care. "As the patient heals, portions of that wound heal over, but two or three small openings remain along the original wound site," Adams says.

If your clinicians count these small openings as separate wounds in later assessments, the patient's wound count looks like it increased (possibly dramatically) on your agency's watch. "You end up with two or three wounds when you started with one," Adams cautions. "Although this is not a true adverse event, but rather an improvement in the patient, the adverse event [report] will pick up more wounds on transfer or discharge than when the patient was admitted."

To avoid this problem, agencies should ensure that their clinicians consistently count a healing wound as one wound.