OASIS C-2 and "Reopened Pressure Ulcers (Injuries)"


I too find the definitions to be confusing. What they are saying is that the closed pressure ulcer’s skin strength is not the same as prior to having a pressure ulcer and due to this, the area is more apt to reopening/breaking down again so it has not been healed. However, the OASIS is using “healed” as being closed.

Based on what I read in the Manual, I would stage it according to the current observations, a stage 2.

Hope this helps!


(M1306) Does this patient have at least one Unhealed Pressure Ulcer at Stage 2 or Higher or designated as Unstageable? (Excludes Stage 1 pressure ulcers and healed Stage 2 pressure ulcers)
Enter Code
No [Go to M1322 ]

Identifies the presence or absence of Unhealed Stage 2 or higher or Unstageable pressure ulcers only.

Start of care.
Resumption of care.
Discharge from agency–not to inpatient facility.

Home health agencies may adopt the NPUAP guidelines in their clinical practice and documentation. However, since CMS has adapted the NPUAP guidelines for OASIS purposes, the definitions do not perfectly align with each stage as described by NPUAP. When discrepancies exist between the NPUAP definitions and the OASIS scoring instructions provided in the OASIS Guidance Manual and CMS Q&As, providers should rely on the CMS OASIS instructions.
Pressure ulcers are defined as 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.
If pressure is not the primary cause of the lesion, do not report the wound as a pressure ulcer.
Terminology referring to “healed” vs. “unhealed” ulcers can refer to whether the ulcer is “closed” vs. “open”. Recognize, however, that Stage 1 pressure ulcers and Suspected Deep Tissue Injury (sDTI), although closed (intact skin), would not be considered healed. Unstageable pressure ulcers, whether covered with a non-removable dressing or eschar or slough, would not be considered healed.
Enter Response 0 (No), if the only pressure ulcer(s) is/are Stage 1 OR healed pressure ulcers (of any previous stage) AND the patient has no other pressure ulcers.
Enter Response 1 (Yes), if the patient has an unhealed Stage 2, Stage 3, OR Stage 4 pressure ulcer OR if the patient has an Unstageable ulcer, defined as: Pressure ulcers that are known to be present but that are unobservable due to a dressing/device, such as a cast, that cannot be removed to assess the skin underneath. “Known” refers to when documentation is available that states a pressure ulcer exists under the non-removable dressing/device.
Pressure ulcers that are present on clinical assessment, but that cannot be staged because no bone, muscle, tendon, or joint capsule (Stage 4 structures) are visible, and some degree of necrotic tissue (eschar or slough) is present that the clinician believes may be obscuring the visualization of Stage 4 structures.

Chapter 3 Section F — Integumentary
OASIS-C2 Guidance Manual Chapter 3: F-4 Effective 1/1/2017 Centers for Medicare & Medicaid Services
Suspected deep tissue injury in evolution, which is defined as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Stage 2 (partial thickness) pressure ulcers heal through the process of regeneration of the epidermis across a wound surface, known as “re-epithelialization.”
Stage 3 and 4 (full thickness) pressure ulcers heal through a process of granulation (filling of the wound with connective/scar tissue), contraction (wound margins contract and pull together), and re-epithelialization (covers with epithelial tissue from within wound bed and/or from wound margins). Once the pressure ulcer has fully granulated and the wound surface is completely covered with new epithelial tissue, the wound is considered closed, and will continue to remodel and increase in tensile strength. For the purposes of scoring the OASIS, the wound is considered healed at this point, and should no longer be reported as an unhealed pressure ulcer.
Agencies should be aware that the patient is at higher risk of having the site 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 full thickness pressure ulcer is only 80% of normal skin tensile strength. Agencies should pay careful attention that preventative measures are put into place that will mitigate the re-opening of a closed ulcer.

From: Dawn Chapman [mailto:dchapman@vnacapecod.org]
Sent: Wednesday, December 07, 2016 3:13 PM
To: Waitt, Maureen (DPH)
Subject: OASIS C-2 and Reopened Stage 3 and 4 Pressure Injuries

October 2016 Q & A’s state that Stage 3 and 4 pressure injuries that are closed are now considered healed. If the area of the Stage 3 or 4 injury reopens as they are apt to do, how is the injury now staged? Does the wound revert to the pressure injury at its worst stage or does the clinician reassess the stage based on the current condition that is seen on assessment?

For example, John Smith has a closed Stage 4 pressure injury to the coccyx. Three weeks after admission the area on his coccyx reopens showing a shallow depth wound with no slough or eschar. Would this then revert back to a Stage 3 pressure injury or would the clinician restage the wound as a Stage 2 pressure injury?


  • edited May 2017
    This is just MY OPINION: That has not been my understanding-- but I
    haven't conferred with CMS or PGBA. But look at the last sentence of the
    OASIS Question Specific Instructions: Agencies should pay careful
    attention that preventative measures are put into place that will mitigate
    the re-opening of a closed ulcer.

    ​If a wound "reopens", that pre-supposes that there was a wound their
    before. What kind of wound was it? If it was a stage 4, then how can it
    "reopen" now as a stage 2? A historically stage 4 wound still cannot heal
    the same way as a stage 2. The wound beds likely look different. I think
    it has to be called a stage 4. The ​part where OASIS and NPUAP disagree
    would be when we call a closed wound a healed wound.


    Daniel P. Clark, RN
  • edited May 2017
    The changing of the CMS definition was basically a way to decrease the clinical points an agency could receive for a closed stage 3 or 4 pressure ulcer/injury.

    This is a case where clinical documentation and OASIS data collection do not match.

    Clinically it is a closed stage 3 or 4 and that is what the nurse should document.
    For the purposes of data collection, there is no wound once it is closed and no longer being treated

    Susan G. Johnsen, RN, MSN, COS-C
    Director, Patient Care. LLUMC Home Health Care
    ph: 909 558 3285

    “Excellence is the Result of Habitual Integrity.”
    Lennie Bennett
  • The little brown CMS based 2017 Instant Oasis Answers book pg.294 (M1311) states, "A previously closed Stage 3 or Stage 4 pressure ulcer that is currently open again should be reported at its worst stage." Example pg. 296 illustrates this, as long as there is no slough/eschar present (making it unstageable).
    Cindy Lashway RN BSN HCS-D
    VNA of Chittenden & Grand Isle Counties, Colchester, VT
  • If a PU opens in a location where there previously had been a PU, you stage the PU to the worst severity it was ever at before it closed/healed. ie- Stage 3 PU closes. reopens and looks like stage 2, but it will really need to be captured on OASIS and documentation as a stage 3.

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