Senior woman with bandage on the hand

State Regulations for Wound Care

With the rise in chronic wounds such as pressure ulcers in the United States, it’s up to long term care facilities to best treat and document wounds to avoid penalties, legal actions and fines.


According to the CDC, between 2% and 28% of patients at skilled nursing facilities now suffer from pressure ulcers. These patients often require specialized wound care treatment offered by trained doctors and nurses. Failure to provide the proper care to patients before and after they develop pressure ulcers can result in F-tag penalties issued by the Department of Health and Human Services.


Facilities that get an F-tag must display them in a public location, and they are reported on federal websites and databases. Many of these F-tags can be avoided by following the proper guidelines and implementing a thoughtful and well-planned wound care program.


There are several factors that go into proper wound care treatment, including effective care planning, healthcare infection prevention and following the proper documentation standards for wound care.

Effective Care Planning


With many diseases now shifting to long-term conditions, the burden of daily and end-of-life care is now centered on facilities outside of hospitals. It’s up to the nurses and doctors at these long-term care facilities to foster effective care plans with patients. So, what exactly is effective care planning and what is the care planning process?


According to the National Institute of Health, effective care planning follows a similar set of guidelines tailored to the patient and his or her needs. Personalized care and support planning are based on discussions between patient and caregiver and an analysis of their chronic condition. An effective care plan provides documentation on the patient’s treatment plan and progress that doctors and nurses use as a guide.


But how effective are care plans in primary care for the patient? According to a recent JAMA article, these plans are only effective if done correctly. That means a detailed central record, allowing patients to play a big role in their care, and a focus on disease management.


End-of-life care and advance care planning are also important to consider. This allows a patient to give instructions as to what happens to them if they become incapacitated by illness or aging. This can be part of an effective care plan at any skilled nursing facility.

Healthcare infection prevention


Keeping the spread of disease to a minimum in a health care facility is vital for people suffering from chronic illness.


Methicillin-resistant Staphylococcus aureus (MRSA) infections mostly occur in health care facilities such as hospitals, nursing homes or dialysis centers. It’s up to these facilities to impose disease prevention measures to protect patients and staff alike.


MRSA tends to attack people with weakened or compromised immune systems, as often is the case with the elderly or patients suffering from chronic disease. Carriers of MRSA are able to spread this antibiotic-resistant staph infection in a health care facility even if they show no symptoms themselves.


Health care workers can help slow the spread of these infections by washing their hands frequently, keeping wounds covered and sanitizing linens and towels. Staffing an Infection preventionist is also a good way to keep infectious disease to a minimum. This person is responsible for tracking diseases and infections, calculating infection rates, overseeing staff training and implementing outbreak prevention measures.


However, not all the responsibility of eliminating infectious disease is on the shoulders of the infection preventionist. Nurses are on the front lines and can stop the spread of disease by monitoring patients, frequently washing their hands and maintaining the most sterile environment possible.


Quality care initiatives in hospitals and health care facilities can also decrease the risk of infectious disease transmission. These initiatives focus on improving the care and outcome for patients.

Wound care fines


Staff at skilled nursing facilities will need to be proficient at treating wounds that do not heal. Nurses can choose to specialize in wound care and have the right skills to treat pressure ulcers, foot ulcers, radiation sores and surgical wounds that aren’t healing.


A pressure ulcer is a common wound in a skilled nursing facility and requires specific care. Pressure ulcers, known as bedsores, can happen to both bedridden and ambulatory patients. To reduce the occurrence of a pressure ulcer, a patient should undergo a complete skin examination upon admission to a long-term care facility. Health care workers can also calculate a patient’s risk for a pressure ulcer using the Braden Scale, which uses several key factors to determine risk. Some of those factors include activity, mobility, friction and nutrition.


Since pressure ulcers are so common amongst nursing home patients, regulatory agencies are cracking down on long-term care facilities that aren’t properly addressing these wounds. Skilled nursing facilities (SNFs) should try to avoid getting F-tags from the Department of Health and Human Services, which are used to mark a deficiency in a particular facility and must be displayed prominently. F-tag 686 has to do with the treatment of pressure ulcers and stipulates: “The facility must ensure that; A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable. A resident who has a pressure ulcer receives care and services to promote healing and prevent additional ulcers”



Working with nurses or doctors who are experts in wound care can reduce CMS penalties for high readmission rates. According to the Center for Medical Studies, of the 14,959 skilled nursing facilities subject to the CMS’ Skilled Nursing Facility (SNF) Value-based Purchasing Program, 73% received a penalty while 27% got a bonus.


Patients who need wound care are those that have a wound that still hasn’t started to heal in two weeks, or that isn’t fully healed in six weeks. It is important that skilled nursing facilities work with physicians specialized in wound care, who can treat patients’ wounds on a weekly basis to avoid the need to send patients to a wound care center. Sending older patients out to a wound care center subjects the patient to further physical stress, as well as places undue stress on the immune system.


Skilled Nursing Facilities that work with wound care physicians are able to better mitigate complications like limb loss and infection for patients. Examples of treatments that a wound care physician can perform within a SNF include sharp debridement, biopsy, negative pressure therapy management, and evaluation and treatment of skin conditions.


When it comes to treatments, who exactly can perform a sharp wound debridement? This type of wound care involves removing dead or infected skin or foreign bodies with the aid of a sharp instrument like a scalpel or pair of scissors. This must be done by a skilled practitioner who is trained in wound care. Physical therapy assistants or physical therapists do not perform this treatment unless they have extensive wound care training; such procedures should be performed by a medical doctor with a surgical background and/or a physician with extensive wound care training.


If a patient at a skilled nursing facility requires wound care, these treatments and procedures are usually covered by insurance.

Documentation Standards for Wounds


Documentation standards for wounds help skilled nursing facilities avoid legal issues. When documenting a wound, there are important steps a provider should take. Some of those include following wound protocol or documenting why you didn’t, using the Braden scale properly, documenting all calls to a physician, following a physician’s orders and documenting exactly what you did, and recording any and all changes to the skin.


If a pressure ulcer is unavoidable, for example, it should be documented as such to prevent future confusion.


If someone has a wound like a pressure ulcer that doesn’t heal within eight weeks, it is considered a chronic wound and needs to be treated accordingly. Often, these wounds are caused by poor circulation, diabetes or a weak immune system. They can become infected, which caregivers will notice with milky gray, yellow or green drainage.


Some ways nurses or doctors treat pressure ulcers and other chronic wounds are with debridement, wound dressings, compression stockings, hyperbaric oxygen treatments and negative pressure wound therapy.  Ultimately, it is necessary to ensure that patients receive comprehensive wound care treatment within the skilled nursing facilities where they reside by a physician that specializes in treating chronic wounds.


However, despite these wound care efforts, some wounds take years to heal–and depending on the practitioner caring for the wound–others may never heal.