Jeri Lundgren, RN, BSN, PHN, CWS, CWCN, CPT

How do we evaluate whether our pressure injury program is ready for the new survey process? 

Audit your program using the tools the Centers for Medicare & Medicaid Services has provided the surveyors for the Long-Term Care Survey Process. 

Start with the LTCSP Initial Pool Care Areas guides. The Initial Pool Process Limited Record Review asks whether the resident developed a pressure ulcer in the facility that has not healed and/or the resident has a pressure ulcer that has worsened and hasn’t improved. You should prioritize those residents, regardless of whether they were in-house or admitted. 

Next, use the LTCSP Initial Pool Care Areas and probes for the resident and representative interviews and resident observations. The interviews will assess the residents’ and representatives’ perceptions of how the wound was acquired, whether staff are treating it, how often they are being repositioned, and if they know whether it is getting better. The resident observation tool will guide you to observe the wound, whether the resident is positioned off the pressure ulcer, and whether the resident remains in the same position for long periods of time. 

Then, for a more in-depth review, use the Critical Element Pathway for pressure ulcers in conjunction with a review of the MDS, physician’s orders, and the care plan. Please note: The LTCSP Procedure Guide states that if pressure ulcer concerns are identified, continuous observations should be performed to determine whether appropriate care and services are provided.

These tools are meant to be guides; the surveyors can ask about and observe other things if they maintain the intent of the care area. These tools can be found at