Pressure ulcer not visualized on recert

Patient has 1 Stage 4 pressure ulcer to R heel and 1 Stage 3 pressure ulcer to sacrum but on recert the nurse didn't visualize the wounds because the caregiver had already changed the dressing. Would it be put as unstageable in that case? There was no order to not remove the dressing. There were no other nursing visits in the 5 day window to make the recert visit. Thanks!

Comments

  • Unless there is doctor documentation specifying the stage as of recent, I would code it "unstageable".

  • They become unstageable then. On EVERY OASIS visit, the RN must be visualizing the wounds, even if the caregiver has already completed care.

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