MDS 3.0 Section M; Skin Conditions: Section M has undergone extensive revisions and careful review of the instructions is imperative. Some key changes include the inclusion by the Centers for Medicare and Medicaid Services (CMS) of an adapted version of the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer definition and staging system as well as evaluation/documentation of a resident's risk for pressure ulcers.  To ensure clinically relevant documentation of pressure ulcers, the assessor completing the MDS will now report the deepest anatomical stage of the ulcer until the ulcer is healed (i.e., clinicians will no longer "back-stage" as was done with the MDS 2.0).

The intent of this chapter is:

• To document the risk, presence, appearance, and change of pressure ulcers.
• To note other skin ulcers, wounds, or lesions, and select treatment/prevention modalities. 

CMS stresses the importance of recognizing and evaluating each resident's risk factors, including through approaches such as completing a standardized risk assessment scale and conducting a full body assessment.  Additionally, determining the etiology of the wound (by the medical provider) ensures an appropriate course of treatment and accurate documentation of the wound on the MDS.

Section M begins by asking what data were used to determine the resident's level of pressure ulcer risk and then asks if the resident is at risk or not.  If a resident is without pressure ulcers, the assessor will skip a great deal of section M.  If there are any current ulcers (in the seven-day look back period), the assessor will then determine the stage of the ulcers and document (for all except stage I ulcers) whether or not the ulcer was present on admission. Regarding determining present on admission, an ulcer is determined not present on admission (i.e., in-house acquired) if it is new or worsens in the nursing home.  Because of this, it is critical that the resident's complete admission skin assessment be well-documented, including the accurate staging of any pressure ulcers.  In the event an ulcer is unstageable (due to eschar and/or slough, suspected deep tissue injury [sDTI] or a nonremovable device), the clinician should document as soon as the area becomes stageable.  The first time that the area becomes stageable (after debridement, the evolution of the sDTI or the removal of the device, respectively), it will be counted as present on admission.  When a resident is hospitalized and the ulcer worsens in the hospital, it would be considered present on admission. These are but a few of the scenarios regarding coding present on admission that CMS offers in the RAI User's Manual.  The assessor should review all the directions carefully regarding this important coding decision.

Harmony Healthcare Presents
AANAC MDS 3.0
 Certification Course

 Casper, Wyoming:   Sept. 28-30, 2010 
 Call 800-530-4413, Ext. 21 to register 

Las Vegas, Nevada:  October 5-7, 2010