Source anchor
CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
Error message
MDS Lookup
Determination of Pressure Ulcer/Injury Risk
Item Rationale
Matrix review
5 matrix group(s) are already attached for review on this item.
Answer coverage
No governed answer rows are attached yet. Add sub-items to populate the answer-codes view.
Answer Codes
No answer codes are defined for this item. This item may use a check-all or numeric entry format.
What this item is
Item Rationale
When to use it
Use this item when the facility is completing content tied to Section M and needs to stay anchored to v1.20.1.
Reminders
- Current source status: Published.
- Item locator: Manual page M-1
- CMS exact locator: Manual page M-1
- This item does not yet have governed answer rows attached.
Source awareness
This page is grounded in CMS MDS 3.0 RAI Manual v1.20.1. Review the exact text and locators before treating the item as final reference content.
Source & Review
Manual
CMS MDS 3.0 RAI Manual v1.20.1
Status
Published
Effective start
2025-10-01
Item locator
Manual page M-1
CMS exact locator
Manual page M-1
Full CMS Text
Item Rationale
Health-related Quality of Life
Pressure ulcers/injuries occur when tissue is compressed between a bony prominence and an external surface. In addition to pressure, shear force, and friction are important contributors to pressure ulcer/injury development. The underlying health of a resident’s soft tissue affects how much pressure, shear force, or friction is needed to damage tissue. Skin and soft tissue changes associated with aging, illness, small blood vessel disease, and malnutrition increase vulnerability to pressure ulcers/injuries. Additional external factors, such as excess moisture, microclimate, and tissue exposure to urine or feces, can increase risk.
Planning for Care
The care planning process should include efforts to stabilize, reduce, or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate based on the individualized needs of the resident. Throughout this section, terminology referring to “healed” versus “unhealed” ulcers refers to whether or not the ulcer is “closed” versus “open.” When considering this, recognize that Stage 1, Deep Tissue Injury (DTI), and unstageable pressure ulcers although “closed” (i.e., may be covered with tissue, eschar, slough, etc.) would not be considered “healed.” Facilities should be aware that the resident is at higher risk of having the area of a closed pressure ulcer open up due to damage, injury, or pressure, because of the loss of tensile strength of the overlying tissue. Tensile strength of the skin overlying a closed pressure ulcer is 80% of normal skin tensile strength. Facilities should put preventative measures in place that will mitigate the opening of a closed ulcer due to the fragility of the overlying tissue.
Steps for Assessment
1. Review the medical record, including skin care flow sheets
or other skin tracking forms, nurses’ notes, and pressure ulcer/injury risk assessments.
2. Speak with the treatment nurse and direct care staff on all
shifts to confirm conclusions from the medical record review and observations of the resident.
3. Examine the resident and determine whether any ulcers,
injuries, scars, or non-removable dressings/devices are present. Assess key areas for pressure ulcer/injury development (e.g., sacrum, coccyx, trochanters, ischial tuberosities, and heels). Also assess bony prominences (e.g., elbows and ankles) and skin that is under braces or subjected to pressure (e.g., ears from oxygen tubing).
Coding Instructions
For this item, check all that apply: Check A if resident has a Stage 1 or greater pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/ device. Review descriptions of pressure ulcers/injuries and information obtained during physical examination and medical record review. Examples of non-removable dressings/devices include a primary surgical dressing, a cast, or a brace.
DEFINITION
HEALED PRESSURE ULCER Completely closed, fully epithelialized, covered completely with epithelial tissue, or resurfaced with new skin, even if the area continues to have some surface discoloration.
DEFINITIONS
PRESSURE ULCER/ INJURY RISK FACTOR Examples of risk factors include immobility and decreased functional ability; co-morbid conditions such as end-stage renal disease, thyroid disease, or diabetes; drugs such as steroids; impaired diffuse or localized blood flow; resident refusal of care and treatment; cognitive impairment; exposure of skin to urinary and fecal incontinence; microclimate, malnutrition, and hydration deficits; and a healed ulcer. PRESSURE ULCER/ INJURY RISK TOOLS Screening tools that are designed to help identify residents who might develop a pressure ulcer/injury. A common risk assessment tool is the Braden Scale for Predicting Pressure Sore Risk©. Check B if a formal assessment has been completed. An example of an established pressure ulcer risk tool is the Braden Scale for Predicting Pressure Sore Risk©. Other tools may be used. Check C if the resident’s risk for pressure ulcer/injury development is based on clinical assessment. A clinical assessment could include a head-to-toe physical examination of the skin and observation or medical record review of pressure ulcer/injury risk factors. Examples of risk factors include the following: — impaired/decreased mobility and decreased functional ability — co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus; — drugs, such as steroids, that may affect wound healing; — impaired diffuse or localized blood flow (e.g., generalized atherosclerosis or lower extremity arterial insufficiency); — resident refusal of some aspects of care and treatment; — cognitive impairment; — urinary and fecal incontinence; — malnutrition and hydration deficits; and — healed pressure ulcers, especially Stage 3 or 4 which are more likely to have recurrent breakdown. Check Z if none of the above apply.
Matrix Applicability
Nursing Home Subsets
NC - Comprehensive
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NQ - Quarterly
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
ND - Discharge
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Swing Bed Subsets
SP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
SD - Discharge
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Stand Alone Assessments
OBRA Admission A=01, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Quarterly A=02, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Annual / Sig Chg A=03, B=99, F=99, G=^, H=0 A= 04, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Discharge A=99, B=99, F=10, 11, G=1, 2, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Program and Policy Use
Administrative (Tech Need / Edits / Processing)
Marker: +
supporting item
Locator: MDS Item Matrix v1.20.1 v4
D/C Items (Only when A0310F = 10 or 11)
A0310G=1 PDC
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
A0310G=2 UPD
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4