OASIS Complete Webinar Series Mastering the OASIS Skin Assessment Presented By: Rhonda Marie Will, RN, BS, HCS-D, COS-C September 10, 2010 243 King Street, Suite 246 Northampton, MA 01060 413-584-5300 fax: 413-584-0220 e-mail: info@fazzi.com www.fazzi.com
Instructions and Handouts for: Fall Risk Assessment 11 12 10 9 8 7 6 1 2 3 4 5 Eastern Standard Time 1:00 PM to 2:30 PM 11 12 10 9 8 7 6 1 2 3 4 5 Central Standard Time 12:00 PM to 1:30 PM 11 12 10 9 8 7 6 1 2 3 4 5 Mountain Standard Time 11:00 AM to 12:30 PM 11 12 10 9 8 7 6 1 2 3 4 5 Pacific Standard Time 10:00 AM to 11:30 AM It is very important that you have these materials printed and ready to use prior to the start of the training. In order to participate in this training you will need to do the following: 1. Dial 1 (877) 615-4339 at least 10 minutes prior to the start of the webinar. 2. When asked, enter Conference ID 8160290#. 3. Give your agency s name. 4. At this time you will be entered into the call and in listen mode. 5. If at any time you need assistance you may press *0 for the operator. 6. There will be a Q & A period toward the end of the session. Questions will be answered in the order in which they are received. To ask a question, press *1. You will have the opportunity to ask your question and then be returned to listen mode. Do not press *1 prior to this time. 7. To view the presentation online you must click on the link sent to you from GoToWebinar. Nurses Only: Directions to receive contact hours for the training. 1. Each participant must complete an evaluation in order to receive contact hours. Click on the following link in order to access the online evaluation form: https://www.surveymonkey.com/s/ltlpspr *Please allow four weeks for processing. Rhonda Will, RN, BS, COS-C, HCS-D is a Senior Clinical Consultant and Assistant Director of the Home Care Quality Institute for Fazzi Associates, Inc. She has thirty eight years experience as a registered nurse and has worked in home health care since 1979 in various clinical, administrative and management roles. Rhonda has extensive experience in staff development and as a trainer. Her areas of expertise include PPS and OASIS assessment skill building, documentation, intake and referral processes, care management, regulatory compliance, and policy and procedure development. With Fazzi Associates Rhonda has developed and provides OASIS clinical training, audit and management training programs and basic ICD-9-CM Coding training. She oversees the team of professional associates who also provides clinical record audits and on site trainings. She presents OASIS and basic coding training on site and by audio conferencing for home health agencies, state home health associations and national professional and commercial organizations. Rhonda provided clinical leadership for the 2003 3M National OASIS Integrity Project. She has developed a reputation in the home health industry as an OASIS Expert and is often interviewed for home health care publications. Rhonda currently serves as a member of the Editorial Board for Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional.
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OASIS-Complete Webinar Series Mastering the OASIS Skin Assessment September 10, 2010 Rhonda Will, RN, BS, COS-C, C HCS-D Assistant Director of OASIS Competency Institute rwill@fazzi.com Fazzi Associates, Inc. 1
Wound Primer Pressure Ulcers Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. 4St Stages + Suspected ddeep Tissue Injury Wound Primer: Definition Pressure Ulcers Partial thickness tissue loss Involves epidermis and into but not through the dermis Superficial; presents as shallow crater, abrasion or blister Heals by epithelialization Regeneration of epidermis across a wound surface Includes Stage I and II pressure ulcers Fazzi Associates, Inc. 2
Wound Primer: Definition Pressure Ulcers Full thickness tissue loss Penetrates through the fat (subcutaneous s tissue) and may involve muscle, tendon, or bone Deep crater; may tunnel Heals by granulation, contraction and epithelialization Never er considered fully healed Closed when fully granulated and covered with new epithelial tissue Includes Stage III and IV pressure ulcers Suspected Deep Tissue Injury (SDTI) Purple or maroon localized area of discolored intact skin OR a blood filled blister due to damage of underlying soft tissue from pressure and/or shear (NPUAP 2007) Fazzi Associates, Inc. 3
Wound Status Not healing Degree/Status of Healing Pressure Ulcer Early/partial granulation Fully granulating Newly epithelialized When epithelial l tissue has completely l covered the wound surface regardless of how long the pressure ulcer has been re-epithelialized. www.wocn.org Wound Guidance Document WOCN Definitions Degree of Healing Not healing Wound with 25% avascular tissue (eschar and/or slough) OR Signs/symptoms of infection OR Clean but non-granulating wound bed OR Closed/hyperkeratotic wound edges OR Persistent failure to improve despite appropriate comprehensive wounds management Early/partial granulation 25% of the wound bed is covered with granulation tissue < 25% of the wound bed is covered with avascular tissue (eschar and/or slough) No signs or symptoms of infection Wounds edges open Fazzi Associates, Inc. 4
WOCN Definitions Degree of Healing Fully granulating Wound bed filled with granulation tissue to the level of the surrounding skin No dead space No avascular tissue (eschar and/or slough) No signs or symptoms of infection Wound edges are open Newly epithelialized Wound bed completely covered with new epithelium No exudate No avascular tissue (eschar and/or slough) No signs or symptoms of infection Definition Unstageable pressure ulcers Pressure ulcer under a dressing or device that cannot be removed Full thickness tissue loss in which the true wound depth is obscured by slough and/or eschar in the wound bed Suspected deep tissue injury in evolution Fazzi Associates, Inc. 5
Alerts! Stage II pressure ulcers and stasis ulcers that close/heal/fully epithelialize are not reportable on OASIS and will not be newly epithelialized for data collection. Stage II pressure ulcers do not granulate and can only be not healing for data collection. M1306 Unhealed Pressure Ulcer Stage II or Higher Is there any kind of a pressure ulcer that is not a Stage I? Fazzi Associates, Inc. 6
M1307 Oldest Non-epithelialized Stage II Pressure Ulcer - DC Identifies: length of time a Stage II PU remained unhealed patients who developed Stage II PU while receiving care from the HHA. M1308 Current Number of Unhealed Pressure Ulcers/Stage Number of ulcers present on the day of assessment Number of ulcers in Column 1 that were also present at the most recent of SOC/ROC Fazzi Associates, Inc. 7
Patient 1 at SOC, has no unhealed Stage II Pressure Ulcer. There are no pressure ulcers. Patient 1 at Follow up he has one Unhealed Stage II PU. Fazzi Associates, Inc. 8
Patient 2 at SOC has one unhealed Stage III Pressure Ulcer. Patient 2 at Follow-up, the Stage III PU has progressed to a Stage IV PU. Fazzi Associates, Inc. 9
Patient 3 at SOC has 1 unhealed Stage II PU. Patient 3 at Discharge, the Stage II PU that was present at SOC has healed. A new Stage II PU developed and is present. Fazzi Associates, Inc. 10
Patient 4 at SOC has 1 unhealed Stage II PU and one closed Stage III PU. Patient 4 at Discharge, the Stage II PU that was present at SOC has healed. A new Stage II PU and the closed Stage III PU and is present. Fazzi Associates, Inc. 11
Patient 5 at SOC has 1 unhealed Stage II PU, 1 unhealed Stage III PU and one closed Stage III PU. Patient 5 at Discharge, the Stage II PU that was open at SOC has healed. A different Stage II PU is open in another location. The Stage III PU remains unhealed and the other Stage III PU remains closed. Fazzi Associates, Inc. 12
Patient 6 at SOC has 1 unhealed Stage II PU, 1 unhealed stage III PU and one closed Stage III PU. Patient 6 at recert, the Stage II PU that was open at SOC has fully reepithelialized. Another Stage II PU is open in a different location. The Stage III PU now has bone exposed and the other Stage III PU remains closed. Fazzi Associates, Inc. 13
Patient 7 at SOC has 1 PU on the left heel covered with eschar and 1 blood filled blister on the right heel from pressure after many days of bed rest. There is a Stage III PU which closed in the hospital and remains closed. Patient 7 at recert the 1 PU on the left heel remains covered with eschar. The blood filled blister on the right heel has broken open and is now a Stage III PU. The Stage III PU which closed in the hospital remains closed now. Fazzi Associates, Inc. 14
Patient 8 is bedbound. At SOC there is a skin graft on a Stage III PU with orders not to remove the pressure dressing until the physician's visit. There is a deep red, warm and boggy area noted on the right heel. Patient 8 at discharge the graft site has healed with some contracture and discoloration of the graft site and the deep red, warm and boggy area noted on the right heel is resolved. Fazzi Associates, Inc. 15
M1310, M1312, M1314 - Unhealed Stage III or IV Pressure Ulcer with Largest Surface Dimension SOC/ROC/DC Unhealed = non epithelialized (open) or closed Consider all Stage III and IV pressure ulcers from M1308 Col.1 rows b, c, d.2 M1320 Status Most Problematic (Observable) Pressure Ulcer SOC/ROC/DC Alert! Stage II pressure ulcers can only be not healing Only closed Stage III and IV pressure ulcers can be newly epithelialized. Most problematic is a clinical judgment. Fazzi Associates, Inc. 16
M1322 Current Number of Stage I Pressure Ulcers Upon inspection, the patient has one PU on the left heel that is covered with eschar. There is one Stage 3 PU on his sacrum. Granulation tissue is present in the wound bed with areas of slough scattered over 10% of the wound bed. M1324 Stage Most Problematic (Observable) Pressure Ulcer SOC/ROC/FU/DC Unhealed: Stage 1, open Stage II, open or closed stage III or IV (+) Observable: visualized, able to stage Most problematic is a clinical judgment. Fazzi Associates, Inc. 17
M1330 Does this patient have a Stasis Ulcer? Caused by inadequate venous circulation Usually lower leg, often with stasis dermatitis Exclude: arterial lesions and ulcers Upon skin inspection, the patient has one stasis ulcer under an Unna Boot M1332 by physician Current and patient Number report with physician of orders not to change the dressing for 4 days. The other leg has a stasis ulcer (Observable) with beefy red granulation Stasis tissue Ulcers filling 75% of the wound bed. Observable: Can be visualized; not covered by non-removable dressing or device. Fazzi Associates, Inc. 18
M1334 Status Most Problematic (Observable) Stasis Ulcer Do not use! Not a response option! Alert! A fully epithelialized stasis ulcer is healed and not reported in OASIS items! Surgical Wounds Frequently heal by Primary Intention Wound edges are directly next to one another Little tissue loss, no granulation occurs Wound closure is performed with sutures, staples, or adhesive May heal by Secondary Intention Wound is allowed to granulate If there is any separation of the incision, then healing will be by secondary intention for data collection purposes. Fazzi Associates, Inc. 19
Surgical Wound Scar Surgical wound that has been re-epithelialized (epidermal resurfacing across the entire wound surface) for approximately 30 days or more without dehiscence or signs of infection. How will you know when the 30 days begins? A scar is not reportable for OASIS data collection. Alert! Surgical wounds healing by primary intention do not granulate and can only be not healing or newly epithelialized for data collection. Fazzi Associates, Inc. 20
M1340 Have a Surgical Wound? Unhealed wound resulting from a surgical procedure. Include: Stapled or sutured incisions Wounds/I&D with drain placement except ostomy Oth Orthopedic pin sites Muscle flap, skin advancement flap, or rotational flap to surgically replace a pressure ulcer Excisions M1340 Have a Surgical Wound? Include: A take down of a previous ostomy Central line sites Medi-port and port-a-cath sites and other implanted infusion devices (e.g. On-Q pump/q p ball, etc.) and venous access devices regardless of functionality (AV shunt, peritoneal dialysis catheter) Shave, punch or excisional biopsy Arthrocentesis Left Ventricular Assist Device/HeartMate Fazzi Associates, Inc. 21
M1340 Have a Surgical Wound? Exclude: PICC line peripherally inserted and Peripheral IV Pressure ulcer treated with surgical debridement An existing wound treated by debridement or skin graft Old surgical wound with scar or keloid formation Ostomies even with drains (e.g. thoracostomy/chest tube, etc.) Cardiac catheterization and/or stent placement via a puncture with a needle Needle aspiration without drain placement Enterocutaneous fistula Retention suture with a button The patient has a surgical wound with a dressing and an order not to change it until after the doctor s appointment in 3 days. There M1340 is one other Have healing a surgical Surgical wound from Wound? a drain that was removed and described as well approximated with some serous crusting. Report surgical wounds that are unhealed and have not become a scar Exception: implanted venous access and infusion devices Fazzi Associates, Inc. 22
M1342 Status of Most Problematic (Observable) Surgical Wound Covered with new epithelial tissue < 30 days Select Response 0 for an implanted venous access or infusion device when it is the only surgical wound and the insertion site is healed. The patient had a hip replacement 4 weeks ago. One week ago M1342 the therapist Status noted that of the Most surgical Problematic wound completely reepithelialized without S/S of a complication. On this DC visit, the wound (Observable) is described as well Surgical approximated, Wound completely reepithelialized with no scabbing or S/S of infection. Fazzi Associates, Inc. 23
M1350 Have a Skin Lesion or Open Wound Receiving Intervention Select YES : Other wound types (burns, diabetic ulcers, cellulitis, Clinical abscesses, intervention: wounds caused by trauma, etc) receiving clinical intervention On-going clinical assessment or treatment as evidenced by orders on home the health POCagency Non bowel ostomies receiving clinical intervention per the POC/485 (e.g., cleansing, dressing changes, etc) from the Select NO : pressure and stasis ulcers, surgical wounds; other types of skin lesions not receiving clinical intervention Status of Healing Possible for OASIS Wound types Not healing Early/partial granulation Fully granulating Newly epithelialized Scar/healed and not reported on OASIS Stage 1 PU Stage 2 PU Stage 3 PU Stage 4 PU Closed Stage 3 or 4 PU Stasis ulcer Surgical Wound Primary Intention Surgical Wound Secondary Intention Fazzi Associates, Inc. 24
Resources National Pressure Ulcer Advisory Panel www.npuap.org p Wound Ostomy Continence Nurses www.wocn.org S.Baranoski and E.A. Ayello, Wound Care Essentials: Practice Principles, Wolters Kluwer Lippincott Williams &Wilkins, Second edition, 2008 OASIS C Guidance Manual CMS OASIS Q and A Fazzi Associates, Inc. 243 King Street, Suite 246 Northampton, MA 01060 413-584-5300 www.fazzi.com Fazzi Associates, Inc. 25