In Appendix PP of the State Operations Manual, Tag F686 for Treatment/Services to Prevent/Heal Pressure Ulcers outlines the following requirements:

483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that—(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

The surveyor guidance for F686 defines “avoidable” and “unavoidable” pressure ulcers.

“Unavoidable” means that the resident developed a pressure ulcer/injury even though the facility had evaluated the resident’s clinical condition and risk factors; defined and implemented interventions that are consistent with resident needs, goals, and professional standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.

The ultimate goal for the facility is that any pressure ulcers that develop in-house occurred because they were unavoidable. So where do facilities most often go wrong when it comes to meeting this goal?

In many cases, the facility documentation fails to fully support the following:

      1. The facility determined and implemented interventions that are consistent with the resident assessment, (the needs, goals, and professional standards of practice);
      2. The facility monitored and evaluated the effectiveness of the interventions; and
      3. The facility revised the interventions as appropriate.

Documentation of Prevention Efforts

While most facilities have assessed that friction/shearing and pressure are risk factors for the resident on admission, they frequently do not take credit for all that is being done to prevent skin breakdown.  Documentation on the care plan, Kardex, treatment record and progress notes often fail to full describe the pressure management/anti-shearing surfaces being used in the bed and chair from the time of admission.  In failing to document these measures from the start of the stay (when the resident often does not have any skin issues,) providers cannot support that these interventions were in place for prevention should pressure ulcer develop.

Timely and Accurate Skin Assessments

In addition, professional standards of care for wound management include completing a weekly head to toe skin assessment and weekly wound assessment if wounds are present.  It is not unusual to find weekly skin assessments that state “no new skin issues identified”.  Unfortunately, this statement implies that there may be ongoing skin issues that have not been further assessed or described.   Another common issue is weekly wound assessments that are inconsistent from week to week.  Each nurse completing the assessment might describe the wound in a slightly different location, for example one week it is documented as on the lower gluteal cleft, the next it might be the coccyx, the next the sacrum.  The wound location should be consistent throughout the existence of the wound until healed, unless it increases in size creating the need for a different location to be used.  Also, wound measurements may reverse from week to week.  Standards of practice dictate that wounds should always be documented as length by width by depth in centimeters, with length in the head-to-toe direction of the wound, width perpendicular to the length, and depth in the deepest part of the wound.


Ongoing monitoring and evaluation of the effectiveness of skin/wound interventions and revision of interventions are the next critical areas to address in documentation.  If a wound demonstrates a plateau in healing progress for 2 or more weeks, or a sudden decline in status such as an increase in size or signs/symptoms of infection, documentation should reflect notification of the resident/representative and physician and a change/revision in orders to address the “root cause” of the decline.  If the resident is choosing not to comply with the turning/repositioning schedule or the ordered treatments, the facility documentation must support the ongoing efforts to educate the resident of the impact of these choices on their condition and what efforts are being made to overcome the choice not to comply.


A facility can never go wrong by taking the time to document all efforts by the facility in skin and wound management.  This will ultimately save an even greater amount of time trying to prove what was done when questioned by a surveyor or an attorney.

Join us October 4, 2022 for additional tips and strategies provided during the webinar:  Survey Success! Avoiding Top Citations. #9 Top Citation: F686 Treatment/Services to Prevent/Heal Pressure Ulcers. Learn more and register!


Janine Lehman, RN, RAC-CT, CLNC
Director of Legal Nurse Consulting

Learn more about the rest of the Proactive team.