Improving performance in pressure ulcer/injury prevalence rates within your facility will result in many benefits including improved quality measures, star ratings, survey results, and patient outcomes. If your facility’s pressure ulcer rate is above industry benchmarks or is increasing, initiating a quality improvement plan and monitoring process is imperative. It is necessary to objectively assess current processes and practices related to pressure ulcer prevention and management to identify areas requiring focused improvement.

Policy and Procedures

One of the initial improvement plan interventions recommended is a review of pressure ulcer-related regulations and corresponding facility policies. Top pressure ulcer-related regulations include F686 Pressure Ulcer, F684 Quality of Care related to pressure ulcers, and F578 related to resident refusal of treatment.   Policies should comply with regulations and current, evidence-based clinical resources.  Additionally, appropriate personnel should be trained on procedures and policies should be easily accessible for reference.

Risk Assessment

Several factors place a resident at risk for developing a pressure ulcer/injury.  All residents should be evaluated for pressure ulcer risk with a validated risk assessment tool (i.e. Braden or Norton)  periodically through the length of stay including within the first 24 hours of admission/readmission, once weekly for the first four weeks, quarterly, and with a change in condition.  While these risk assessment tools generate a total score indicative of risk level, we must review each triggered risk category separately. A risk assessment must be used in combination with clinical judgment to assess each resident’s unique pressure ulcer risk(s), so that a person-centered, individualized plan of care based on specific risk factors and co-morbidities can be developed.

Skin Assessment & Evaluation

Consistent and thorough assessment of skin integrity, including evaluation of current unhealed pressure ulcers is a key process for preventing and/or healing pressure ulcers/injuries. A head-to-toe skin examination should be completed at specified frequencies to identify any impairment to skin or potential complications. Best practice dictates that an initial skin assessment is performed within hours of admission as an individual can potentially develop a pressure ulcer/injury within hours of the onset of unrelieved pressure. Following this baseline evaluation, a full skin assessment should be performed no less than once weekly.  Where possible, it is ideal to have the same nurse(s) evaluate and document skin conditions for greater consistency and the increased ability to identify subtle changes; however, all staff should be knowledgeable regarding pressure ulcer prevention, evaluation, and performing skin treatments. Routine pressure ulcer prevention and treatment education and competencies should be completed and documented for nursing staff.

To promote an interdisciplinary approach to pressure ulcer/injury prevention and management, a weekly clinical “at-risk” meeting can be held and should include a comprehensive review of those residents identified as currently having or are at risk for developing a wound and/or nutritional concern.  For those with an unhealed pressure ulcer/injury, a tracking form or report for each pressure ulcer is needed to evaluate wound healing progress or complication.  The treatment plan should be re-evaluated and revised with any changes and if there is no progression toward healing after two weeks of the current treatment plan.  In cases where signs of healing are not seen, the physician should be contacted and appropriate treatment orders should be obtained promptly. A root cause analysis is necessary with occurrences of new or non-healing pressure ulcer(s) to determine causation and possible system improvement opportunities.


Pressure ulcer assessment and documentation includes the following:

1.       Location
2.       NPUAP staging
3.       Measurements
4.       Undermining or tunneling
5.       Wound base, edges & surrounding tissue
6.       Exudate or drainage
7.       Odor
8.       Signs of infection
9.       Pain
10.   Treatment description
11.   Progress


Facilities need to ensure that a process exists for both resident/resident representative and physician notification with any occurrence of a new pressure ulcer, and/or deterioration or lack of progression toward healing after two weeks, and when a wound heals.  It is also important to communicate any risks identified that may contribute to pressure ulcer/injury development and the interventions the facility staff will be implementing to mitigate the risk(s) as much as possible. A method for providing a resident and their family education related to prevention and treatment of pressure ulcers should be included as part of the communication process. For staff, promote communication of resident status and changes from baseline (including changes in skin integrity) through meaningful shift change reports, “huddle” meetings, and care plan review.   Written or electronic documentation forms should be available to nurse aides to communicate skin abnormalities to the nurse for acknowledgment and follow-up.

Care Plan

A baseline care must be developed for each resident within 48 hours of admission and should include pressure ulcer risk factors, skin conditions and interventions.  The individualized comprehensive care plan should reflect Care Area Assessment (CAA) analysis and risk-related factors.  The care planning process is ongoing and does not stop with the comprehensive or quarterly assessment.  Care plan revision should occur with changes in skin condition and new development of risk factors and/or pressure ulcers. As mentioned above, communication of the care plan is highly important and it should be available to appropriate staff for review and revision as necessary. Oversight of the “real-life” implementation of interventions should be an ongoing monitoring activity for your facility.


The Resident Assessment Instrument (RAI) manual has specific definitions and guidance which must be followed to accurately code MDS Section M: Skin Conditions.  Although CMS has worked toward consistency, this guidance may vary from NPUAP guidelines.  Even so, the MDS assessment must be coded per RAI Manual instructions. If inconsistencies occur, reach out to the treating clinician for clarification and document discussions and clarifying factors in the medical record. Relevant to Quality Measures, it is important to code pressure ulcers that were present upon admission/entry or reentry correctly.  MDS coding of specific items impacts the long and short stay pressure ulcer quality measures and in turn, the CMS quality measures star rating.   Section M coding will indicate whether or not a pressure ulcer was present upon admission, for example, or developed or worsened under our care.  Additionally, if specific ADLs in Section G are not reported accurately, residents may be excluded from your High-Risk Pressure Ulcer QM denominator and obscure the facility prevalence rate.  In a recent study, the Med Analytics analyses project compared self-reported data from the Minimum Data Set including pressure ulcers in contrast to hospital documents for readmitted residents.  The data revealed that nursing homes underreported by approximately half.

Strong systems for driving pressure ulcer prevention, assessment, and management are critical, as well as regular monitoring of coding accuracy and supportive documentation for section M.


Regulatory Compliance

Surveyors utilize the Pressure Ulcer CE Pathway to determine if facility practices are in place to identify, evaluate, and intervene to prevent and/or heal pressure ulcers.


Ongoing review and trending of pressure ulcer data should include prevalence and incident rates. These rates are to be reviewed as part of your QAPI activities.  Progress should be conveyed to key stakeholders and direct care staff. CMS has created a Process Tool Framework to reference each CMS Process Tool of the Five Elements of QAPI.  This framework includes a description of the purpose or goal for each tool that is hyperlinked within the framework. Click here for A Process Tool Framework (PDF).


      • Centers for Medicare and Medicaid Services (CMS). (2020, January 1). MDS 3.0 Quality Measures USER’S MANUAL, 13.0.
      • Centers for Medicare and Medicaid Services. (2019). MDS 3.0 RAI Manual. Retrieved from:
      • CMS State Operations Manual. Transmittal. Rev. 11-22-17.
      • Health Services Advisory Group.  Quality Measure Tip Sheet: Pressure Ulcers—Long Stay.
      • Integra Med Analytics.  (2020, August 25). Underreporting in Nursing Home Quality Measures.
      • The National Pressure Ulcer Advisory Panel (NPUAP) – Educational & Clinical Resources


Blog by Kristen Walden, MSN, RN, RAC-CT, Proactive Medical Review

Learn more about Kristen and the rest of the Proactive team.