Source anchor
CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
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MDS Lookup
Unhealed Pressure Ulcers/Injuries
Item Rationale
Matrix review
7 matrix group(s) are already attached for review on this item.
Answer coverage
2 governed answer row(s) are attached for this item.
Answer Codes
Code 0
No
if the resident did not have a pressure ulcer/injury in the 7-day look-back period. Then skip to M1030, Number of Venous and Arterial Ulcer...
Code 1
Yes
if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period. Proceed to M0300, Current N...
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-4
- CMS exact locator: Manual page M-4
- This item has 2 governed answer row(s) 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-4
CMS exact locator
Manual page M-4
Full CMS Text
Item Rationale
Health-related Quality of Life
Pressure ulcers/injuries and other wounds or lesions affect quality of life for residents because they may limit activity, may be painful, and may require time- consuming treatments and dressing changes.
Planning for Care
The pressure ulcer/injury definitions used in the RAI Manual have been adapted from those recommended by the National Pressure Ulcer Advisory Panel (NPUAP) 2016 Pressure Injury Staging System. An existing pressure ulcer/injury identifies residents at risk for further complications or skin injury. Risk factors described in M0100 should be addressed. For MDS assessment, initial numerical staging of pressure ulcers and the initial numerical staging of ulcers after debridement, or DTI that declares itself, should be coded in terms of what is assessed (seen or palpated, i.e. visible tissue, palpable bone) during the look-back period. Nursing homes may adopt the NPUAP guidelines in their clinical practice and nursing documentation. However, since CMS has adapted the NPUAP guidelines for MDS purposes, the definitions do not perfectly correlate with each stage as described by NPUAP. Therefore, you must code the MDS according to the instructions in this manual.
DEFINITION
PRESSURE ULCER/INJURY A pressure ulcer/injury is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful. Pressure ulcer/injury staging is an assessment system that provides a description and classification based on visual appearance and/or anatomic depth of soft tissue damage. This tissue damage can be visible or palpable in the ulcer bed. Pressure ulcer/injury staging also informs expectations for healing times. The comprehensive care plan should be reevaluated to ensure that appropriate preventative measures and pressure ulcer/injury management principles are being adhered to when new pressure ulcers/injuries develop or when existing pressure ulcers/injuries worsen.
Steps for Assessment
1. Review the medical record, including skin care flow sheets or other skin tracking forms.
2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical
record review.
3. Examine the resident and determine whether any skin ulcers/injuries are present.
Key areas for pressure ulcer/injury development include the sacrum, coccyx, trochanters, ischial tuberosities, and heels. Other areas, such as bony deformities, skin under braces, and skin subjected to excess pressure, shear, or friction, are also at risk for pressure ulcers/injuries. Without a full body skin assessment, a pressure ulcer/injury can be missed. Examine the resident in a well-lit room. Adequate lighting is important for detecting skin changes. For any pressure ulcers/injuries identified, measure and record the deepest anatomical stage.
4. Identify any known or likely unstageable pressure ulcers/injuries.
Coding Instructions
Code based on the presence of any pressure ulcer/injury (regardless of stage) in the past 7 days.
Code 0, no: if the resident did not have a pressure ulcer/injury in the 7-day look-back
period. Then skip to M1030, Number of Venous and Arterial Ulcers.
Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or
unstageable) in the 7-day look-back period. Proceed to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
Coding Tips
If an ulcer/injury arises from a combination of factors that are primarily caused by pressure, then the area should be included in this section as a pressure ulcer/injury. Mucosal ulcers caused by pressure should not be coded in Section M. Oral mucosal ulcers are captured in item L0200C, Abnormal mouth tissue. Mucosal pressure ulcers are not staged using the skin pressure ulcer staging system because anatomical tissue comparisons cannot be made. Therefore, mucosal ulcers (for example, those related to nasogastric tubes, nasal oxygen tubing, endotracheal tubes, urinary catheters, etc.) should not be coded here. If a pressure ulcer is surgically closed with a flap or graft, it should be coded as a surgical wound and not as a pressure ulcer. If the flap or graft fails, continue to code it as a surgical wound until healed. Residents with diabetes mellitus (DM) can have a pressure, venous, arterial, or diabetic neuropathic ulcer. The primary etiology should be considered when coding whether a resident with DM has an ulcer/injury that is caused by pressure or other factors. If a resident with DM has a heel ulcer/injury from pressure and the ulcer/injury is present in the 7-day look-back period, code 1 and proceed to code items in M0300 as appropriate for the pressure ulcer/injury. If a resident with DM has an ulcer on the plantar (bottom) surface of the foot closer to the metatarsals and the ulcer is present in the 7-day look-back period, code 0 and proceed to M1040 to code the ulcer as a diabetic foot ulcer. It is not likely that pressure is the primary cause of the resident’s ulcer when the ulcer is in this location. Scabs and eschar are different both physically and chemically. Eschar is a collection of dead tissue within the wound that is flush with the surface of the wound. A scab is made up of dried blood cells and serum, sits on the top of the skin, and forms over exposed wounds such as wounds with granulating surfaces (like pressure ulcers, lacerations, evulsions, etc.). A scab is evidence of wound healing. A pressure ulcer that was staged as a 2 and now has a scab indicates it is a healing stage 2, and therefore, staging should not change. Eschar characteristics and the level of damage it causes to tissues is what makes it easy to distinguish from a scab. It is extremely important to have staff who are trained in wound assessment and who are able to distinguish scabs from eschar. If two pressure ulcers/injuries occur on the same bony prominence and are separated, at least superficially, by skin, then count them as two separate pressure ulcers/injuries. Stage and measure each pressure ulcer/injury separately. If a resident had a pressure ulcer/injury that healed during the look-back period of the current assessment, do not code the ulcer/injury on the assessment. Skin changes at the end of life (SCALE), also referred to as Kennedy Terminal Ulcers (KTUs) and skin failure, are not primarily caused by pressure and are not coded in Section
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
NPE - PPS DC
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
Program and Policy Use
PDPM
Marker: +
supporting item
Locator: MDS Item Matrix v1.20.1 v4
Shared NH/SB Subsets
IPA - Interim Payment
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
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
Item Subset Required Use ISC Skip Patterns
PDPM (A0310B = 01 or 08)
Marker: +
supporting item
Locator: MDS Item Matrix v1.20.1 v4