Skin in the MDS game
Skin in the MDS game
The Minimum Data Set 3.0 has a lot of moving parts — nowhere more so than in Section M: Skin Condition.
For clinicians in long-term care, it means a formidable challenge. Trying to complete the section while trying to match MDS documentation with what is actually occurring with a resident takes especially skillful execution, skin care specialists say.
It has become paramount that everyone in the organization be knowledgeable, accurate and, most importantly, accountable for the prevention of skin irritations that can lead to pressure ulcers and other infections requiring costly hospital readmission.
If wounds are not adequately assessed and documented in Section M, for instance, outcomes of care cannot be evaluated, and treatment and prevention plans are rendered inadequate. Not only does this result in less than optimal outcomes, it gives rise to potential lawsuits for inadequate care against both the caregiver and facility.
“The elements of a good skin care program at a long-term care facility center around prevention,” says Frances E. Schuda, RN, MSN, interim nursing program director at Harcum College in Bryn Mawr, PA, and a member of the Wound, Ostomy and Continence Nurses Society Accreditation Committee.
Creating a sound prevention program involves significant education for the direct care staff and consists of practices such as bathing seniors with pH-appropriate cleansers and applying moisturizers immediately after bathing, Schuda says. Cleaning the skin after an incontinent episode is especially critical, she explains, including the application of skin barriers to intact skin.
“Hydration assists with skin turgor, which is always helpful to overall skin health,” she says. “Frequent position changes, ambulation and use of proper fitting shoes are key.”
It is also important for caregivers to be cognizant of how aging causes skin changes in terms of elevated risk for breakdown and infection, says Elaine McGowan, RN, vice president of clinical affairs for DermaRite Industries.
“Dry skin is thinner, more fragile and may be prone to itching, which can lead to scratching,” she says. “Repeated or intense scratching can open the skin and provide an entry for pathogens.”
Using pH-balanced products helps to maintain the acid mantle, which is the skin's natural defense against the growth of harmful microorganisms on it, McGowan says. Moisturizers should be applied as soon as possible after bathing, she adds, in order to repair or augment the skin's own natural moisture barrier and prevent transepidermal water loss.
Organize a team
F. Alex Khan, advanced practice nurse and adult clinical nurse specialist with Pro Healthcare Consulting Group, recommends putting together an interdisciplinary team comprising a registered nurse, licensed practical nurse, physical and occupational therapists, dietitian, physician, social worker and nursing assistant. Nurse members should work together to identify and develop individualized care plans, complete MDS and work closely with the physician to treat wounds and address skin issues. PTs and OTs can evaluate the patient's mobility status and physical activity, the dietitian designs an optimal nutrition plan and the social worker identifies the patient's family and financial status.
“Every long-term care facility must have a comprehensive wound and skin care program focused on prevention and management of wounds in the elderly,” Khan says. “Efficacy of the wound and skin care program depends on the interdisciplinary team focused on working together to prevent and treat issues with skin integrity. A wound and skin care program is designed to standardize care and deliver comprehensive, integrated evidence-based skin and wound care.”
‘Head to toe'
Section M explores skin assessment so thoroughly that “there is no way to accurately answer the questions without a nurse having done a complete head-to-toe skin assessment of the resident,” states Judi Kulus, RN, vice president of curriculum development for the American Association of Nurse Assessment Coordination. “In the very first item of Section M, the nurse assessor is asked to determine whether the resident is at risk for developing pressure ulcers.
“This can be done by using a formal assessment tool, such as the Braden Scale. When facility staff embrace the (Resident Assessment Instrument) assessment process from start to finish, they increase the likelihood of identifying risk factors and this in turn leads to an effective care plan.”
Section M is indeed “very important” since its components lead staff to develop and revise an individualized plan of care for each resident based on risk category and skin assessment, Schuda says.
“All characteristics of any existing ulcers must be noted, including treatment measures,” she notes.
From that information, MDS provides detailed information about an individual and allows the interdisciplinary team to implement interventions based on the identified risks, Khan says. For example, he says a patient who is identified as “incontinent and bedbound” shall have an individualized care plan developed to address nutrition, pressure relief measures and skin care treatments to prevent skin breakdown.
Once the Section M items are complete, “the critical thinking and in-depth analysis of the resident's pressure ulcer risk and interventions begins,” Kulus says. Using the Review of Indicators of Pressure Ulcers (CAA 16) provided in Appendix C of the RAI, the assessor is guided through a methodical analysis of pressure ulcer risk factors, contributing factors, and factors needing consideration when developing the resident-focused care plan.
“Accuracy is critical,” Kulus says, referring to a 2012 report from the Office of Inspector General, which indicated “for the items related to skin conditions and treatments, SNFs did not always report the correct number or stage of skin ulcers or they reported the presence of burns or open lesions inaccurately … they also did not always correctly report skin treatments, such as surgical wound care or ulcer care.”
On at least four occasions, the RAI advises the resident's “overall” clinical condition be assessed or reassessed, Kulus says. For example, if a pressure ulcer fails to show some evidence toward healing within 14 days, the ulcer, its potential complications and the patient's overall clinical condition should be reassessed.
“There are two notable instructions in that sentence,” she says. “One, if a pressure ulcer does not make progress in 14 days, the treatment plan should be changed and another comprehensive assessment should be completed. Two, continual assessment and reassessment should be undertaken until a pressure ulcer is healed.”
Though following the MDS is standard practice, skin care specialists maintain that its main function is to serve as a tool. It is not the ultimate authority for wound care.
Khan notes the MDS only gives a “basic level of prevention and management options.”
“It does not address complex or atypical skin issues associated with chronic diseases,” he says. Registered nurses completing the MDS form must have additional wound and skin care training to complete it properly, he adds.
Moreover, “MDS is not a prescriptive document to categorize skin risk factors and pressure ulcers and does not suggest any treatment modalities,” Schuda says. “Staff should refer to current evidence-based practice guidelines, such as WOCN clinical practice guidelines or [Agency for Healthcare Research and Quality] regarding treatment plans for wound care.”
Having access to a clinical expert in the areas of wounds and continence will greatly benefit staff by providing education, clinical assessments and assistance with facility policies and procedures in developing guidelines for skin care prevention techniques and pressure ulcer management, Schuda says.
“The guides for appropriate treatment should be generated by the facility policies and procedures and hopefully, these are guided by evidence-based research and practices,” she says. “Advanced treatments and assessments should be under the direction of an expert in this field, namely a WOCN nurse.”