Defending against complaints arising from the development of a pressure sore located in the sacrum or coccyx area typically involves determining whether the wound was avoidable or unavoidable. Although we have successfully relied upon the Long Term Care Surveyor’s Guidelines to successfully define unavoidable wounds, the Center for Medicare and Medicaid Services (CMS) recently provided defense counsel with another useful tool when it recognized that a Kennedy Terminal Ulcer (KTU) is not a pressure ulcer and is not caused by poor care. While health care providers have been familiar with the concept of a Kennedy Terminal Ulcer for almost 20 years, formal recognition of a KTU goes a long way in legitimizing the concept that certain medical conditions can lead to unavoidable pressure ulcers that are not indicative of inadequate quality of care.
Mandatory documentation in the Minimum Data Set (MDS) is a quality reporting program in place for Skilled Nursing Facilities. Beginning January 1, 2014, the Affordable Care Act mandates a similar quality reporting program for Long-Term Care Hospitals, Inpatient Rehabilitation Hospitals, and Hospice programs. The facilities will be required to collect data within the LTCH Continuity Assessment Record & Evaluations (CARE) Data Set which will assess three quality indicators, 1) Catheter-Associated Urinary Tract Infections, 2) Central line Catheter-Associated Blood Stream Infections, and 3) Pressure Ulcers that are New or Have Worsened. The Kennedy Terminal Ulcer was not mentioned in the final rule, however it is incorporated into a draft of the LTCH Quality Reporting Program Manual recently released and available on the CMS website. The skin section of the CARE Data Set is designated Section M, and is very similar to requirements in the MDS that apply to Medicare Certified Skilled Nursing Facilities. One major exception is found in the Coding Tips, where the Kennedy Terminal Ulcer is specifically mentioned:
“Skin ulcers that develop in patients who have terminal illness or are at the end of life should be assessed and staged as pressure ulcers until it is determined that the ulcer is part of the dying process (also known as Kennedy ulcers). Kennedy ulcers can develop from 6 weeks to 2 to 3 days before death. These ulcers present as pear-shaped purple areas of skin with irregular borders that are often found in the sacrococcygeal areas. When an ulcer has been determined to be a Kennedy Ulcer, it should not be coded as a pressure ulcer.”
These instructions potentially eliminate (based on resident assessment), reporting new pressure ulcers in persons who are expected to die in Long-Term Acute Care hospitals. The rationale for the requirements recognizes that skin and soft tissue changes associated with aging, illness, small blood vessel disease and malnutrition increase vulnerability to pressure ulcers. In light of these new guidelines, it will be important for MDS personnel to appropriately assess wounds and not code them as a pressure ulcer in the MDS when it is determined that a wound is a Kennedy Terminal Ulcer.
In long term care litigation, when presented with allegations that poor care allowed a resident to develop a pressure sore at the coccyx or sacral area, consideration should always be given to whether the wound was unavoidable and, if the wound developed near the end of a patient’s life, using CMS criteria to assist in defining that the wound is a Kennedy Terminal Ulcer and not a pressure ulcer. If a Kennedy Terminal Ulcer is considered, early identification of a knowledgeable expert is essential to assist with developing a theory that the resident was in the dying process. In essence, the expert will need to provide opinions that the resident’s organs and systems were shutting down, including the largest organ, the skin, and this resulted in the development of a coccyx or sacral wound that was unavoidable and was not a pressure ulcer.
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