Q:
Patient was admitted with a stage IV pressure ulcer that healed (fully epithelialized) and several months later reopened at the same site. How should this pressure ulcer be staged when it reopens?
A:
According to the RAI Manual guidance for pressure ulcer staging, the accurate staging of ulcers requires a thorough review of the history of each pressure ulcer. Careful documentation and tracking of pressure ulcers is essential to accurate staging. Upon healing, a pressure ulcer should be documented as a healed ulcer as its highest stage, which in this case would be a healed stage IV pressure ulcer. The area remains a risk for future breakdown and/or injury since it has “closed, ” but lost muscle, fat and dermis tissue are not replaced when re-epithelialized.
As a result the guidance clarifies that a previously closed pressure ulcer that opens again should be reported at the highest stage it was previously, unless currently presenting at a higher stage. In this case, since it was previously a stage IV, which is the highest stage possible, it should be coded as a stage IV, regardless of whether it presents with the appearance of a lower stage. The RAI manual guidance further clarifies that since the initial stage IV pressure ulcer was present on admission the reopened area is also coded “as present on admission”.
Join Proactive August 13, 2024 for webinar training that addresses the risks associated with Pressure Ulcers/Injury. Learn more at: Immediate Jeopardy Risk: Pressure Ulcers
Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Clinical Consultant
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