Q: How can we avoid F-tags for skin integrity and pressure ulcers?

A:  A punitive environment can be minimized with a proactive approach of care and by maintaining standards of practices. The F-tag F 686 is for skin failure and includes F 483.25 (b) for skin integrity and F 483.25 (b) (1)for pressure ulcers. 

The intent from the Centers for Medicare & Medicaid Services is that a resident does not develop pressure ulcers or skin injury unless it is clinically unavoidable, and the facility provides care services that maintain the professional standards of care. 

Multiple risk factors including age, dry skin, previous sun exposure, multiple medications and systemic factors including co-morbidities, can make skin injury unavoidable. As we age, subcutaneous fat decreases, and elasticity of the skin, vascularity, Langerhans cells (the fighter cells in the skin), sweat glands, and thermoregulation are all altered. This leads to weaker skin. Dry skin is one of the most common factors for skin breakdown, and excessive moisture and sweat can cause skin excoriation. 

The history of sun exposure can lead to photoaging. Signs include hyperpigmented skin, fine veins on the surface of sun exposed skin, freckles (melasma), and actinic or seborrheic keratosis. Medications, including some diuretics, antibiotics and local or systemic steroids, also can cause photosensitivity and skin reactions. 

Other risk factors, such as excessive adipose deposition, chronic conditions, acute systemic infections and even stress (which leads to an increase in steroid hormones) can lead to skin damage with the slightest risk for skin integrity. 

 A proactive approach including assessment for risk factors of unavoidable skin breakdown, as well as timely and comprehensive documentation, are the first steps for standards of practice.

Fatima Naqvi, MD, CMD, is medical director of AMDA – The Society for Post-Acute and Long-Term Care Medicine. Send her your wounds-related questions at [email protected].