California Nursing Home Abuse Lawyers Blog

Controversy is usually considered undesirable -- in the same category as conflict, discord, and disagreement. However, when it takes the form of respectful dialogue rather than debate, controversy can transform opinion and even give rise to unexpected progress. One hopes, for the benefit of all concerned, that the current controversy surrounding pressure ulcers might bring about a similarly positive outcome.
In 2010 the Centers for Medicare & Medicaid Services (CMS) halted additional payments to hospitals for selected conditions that were acquired in the hospital (in other words, not present when the patient was admitted). One of these conditions was the pressure ulcer, bed sore and the decubitus ulcer which CMS asserted "could reasonably have been prevented through the application of evidence-based guidelines." This regulation was known as the Inpatient Prospective Payment System Fiscal Year 2009 Final Rule (IPPS FY 2009 Final Rule).[1] In IPPS FY 2009 Final Rule, CMS hedges a bit with language. The rule does not state unequivocally that pressure ulcers are always or entirely preventable -- only that they are reasonably preventable. Still, no recourse exists for hospitals to receive any additional reimbursement for the treatment of hospital-acquired pressure ulcers even if clinicians deem them unavoidable.

A reduction in reimbursement is not the only consequence of the CMS ruling. The assertion by CMS that pressure ulcers, bed sores and decubitus ulcers can be prevented raises the legal stakes for nurses because the ruling essentially implies that if a pressure ulcer, bed sore and decubitus ulcer occurs during hospitalization, it must be the result of inadequate nursing care. Patients, families, attorneys, the courts, juries, and the public will now believe that pressure ulcers, bed sores and decubitus can be always be prevented with adequate vigilance and care, leaving nurses and hospitals open to lawsuits every time a pressure ulcer, bed sore and decubitus ulcer appears to have its onset during hospitalization.

A controversy wouldn't be a controversy without 2 points of view. In contrast to CMS's stance, some believe that pressure ulcers will occur, in certain patients, even if staff members follow the best guidelines or use the latest high-tech skin protection devices.
CMS has already maintained, in writing, that pressure ulcers, bed sores and decubitus ulcers are not all preventable, at least in long-term care settings This is true. In their guidance to state and federal surveyors, CMS states that long-term care facilities must ensure that "a resident who enters the facility without pressure sores, bed sores and decubitus ulcers does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. Unavoidability means "the resident developed a pressure ulcer, bed sore and decubitus 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 interventions; and revised the approaches as appropriate.

"Why should the setting matter? We are taking care of the same patients, with the same conditions and comorbidities. It makes no sense to say that a pressure ulcer is avoidable in one venue and unavoidable in a different venue. In hospitals, patients are more acutely ill. At a minimum, I would call it inconsistent public policy."

So, which side of the fence do the experts -- the wound care clinicians -- fall on? Can all pressure ulcers be prevented with the right kind of care? Or is it possible for pressure ulcers to develop despite the best efforts to prevent them?

There is consensus among most wound care clinicians that there is such a thing as an unavoidable pressure ulcer. The debate is about frequency. Some would say they are rare. Others contend that nearly all pressure ulcers are unavoidable because of the underlying comorbidities. These are the 2 extremes, and the truth is probably somewhere in the middle. But if there is such a thing as an unavoidable pressure ulcer, how do we define it? What are the variables that would make a pressure ulcer unavoidable?"

With the most diligent, consistent care, you can reduce the number of facility-acquired pressure ulcers. But no pressure ulcers? "You probably won't get to zero incidence and sustain that, a strong collaborative approach can reduce a facility's incidence of pressure ulcers. At the same time, the continued occurrence of pressure ulcers in certain patients despite appropriate care suggests that there is a floor effect in the prevention of pressure ulcers.

Although opinions may vary on the frequency and circumstances surrounding the unavoidable pressure ulcer, the wound care community does not agree with CMS that all pressure ulcers can be avoided. The WOCN Society are the country's nursing experts in the assessment, prevention, and care of pressure ulcers, and have taken a leadership role in the pressure ulcer controversy. On behalf of nurses who take care of patients at risk for pressure ulcers, the WOCN Society responded to the CMS ruling with the position paper "Avoidable and Unavoidable Pressure Ulcers. This position paper takes the view that pressure ulcers are not entirely avoidable and provides the evidence base to support this stance.