CMS Manual System - Louisiana Department of Health and Hospitals

The definitions for the stages of pressure ulcers identified below are from the Long-Term
Care Facility Resident Assessment Instrument User’s Manual, Version 3.0. 34
―Stage I‖ - An observable, pressure-related alteration of intact skin, whose
indicators as compared to an adjacent or opposite area on the body may include
changes in one or more of the following parameters:
o Skin temperature (warmth or coolness);
o Tissue consistency (firm or boggy);
o Sensation (pain, itching); and/or
o A defined area of persistent redness in lightly pigmented skin, whereas in
darker skin tones, the ulcer may appear with persistent red, blue, or purple
hues.
―Stage II‖ - Partial thickness loss of dermis presenting as a shallow open ulcer
with a red-pink wound bed without slough. May also present as an intact or
open/ruptured blister.
―Stage III‖ - Full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon or muscle is not exposed. Slough may be present but does not obscure the
depth of tissue loss. May include undermining or tunneling.
"Stage IV‖ - Full thickness tissue loss with exposed bone, tendon or muscle.
Slough or eschar may be present on some parts of the wound bed. Often includes
undermining and tunneling.
THE HEALING PRESSURE ULCER
Ongoing evaluation and research have indicated that pressure ulcers do not heal in a
reverse sequence, that is, the body does not replace the types and layers of tissue (e.g.,
muscle, fat and dermis) that were lost during the pressure ulcer development.
There are different types of clinical documentation to describe the progression of the
healing pressure ulcer(s). The regulation at 42 CFR 483.20(b)(1), F272, requires that
facilities use the RAI. Directions on describing pressure ulcer(s) according to the RAI can
be found in the RAI manual – these are intended for coding purposes of the MDS.
(NOTE: For information on coding pressure ulcers for the MDS, see Chapter 3 of the
Long-Term Care Facility Resident Assessment Instrument User’s Manual, Version 3.0,
effective 10/1/2010, which is located on the CMS MDS 3.0 website
(http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#Top
OfPage).