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Hi all. I have heard and read a lot of controversy regarding Kennedy terminal ulcers that is is no longer a valid diagnosis. When a dti suddenly appears a day after admission and patient is on hospice do you still consider it pressure related vs terminal? If terminal how do you document accordingly ? Do kennedy ulcers count as hospital aquired? Thanks.
Nov 6, 2019 by Melissa Khoo,
1 replies
Elaine Horibe Song
MD, PhD, MBA
Hi Melissa

Thanks for your question. Others may have other pieces to add, but our topic "Pressure Ulcer/Injury Assessment" talks about Kennedy Terminal Ulcers, so I'll use it as a reference to the answers below, together with the CMS regulations (CMS State Operations Manual for Long Term Care Facilities): 

Question 1: I have heard and read a lot of controversy regarding Kennedy terminal ulcers that is is no longer a valid diagnosis.
Answer: There is no specific ICD-10 for Kennedy Terminal Ulcer (KTU). KTUs are considered to be PUs/PIs that generally occur at the end-of-life, and thus are coded and staged as PUs/PIs.[1]

Question 2: When a dti suddenly appears a day after admission and patient is on hospice do you still consider it pressure related vs terminal?
Answer: CMS recognizes the that PUs/PIs at the end-of-life may be unavoidable. [1] KTUs have certain characteristics which differentiate them from pressure ulcers such as the following [1]:
• KTUs appear suddenly and within hours;
• Usually appear on the sacrum and coccyx but can appear on the heels, posterior calf
muscles, arms and elbows;
• Edges are usually irregular and are red, yellow, and black as the ulcer progresses, often
described as pear, butterfly or horseshoe shaped; and
• Often appear as an abrasion, blister, or darkened area and may develop rapidly to a
Stage 2, Stage 3, or Stage 4 injury. See pictures on the PU/PI topic (https://woundreference.com/app/topic?id=pressure-ulcersinjuries---introduction-and-assessment#background)
To be considered unavoidable and consistent with regulatory requirements, it is important that clinicians properly document that the the facility has implemented appropriate efforts to stabilize the resident’s condition (or indicted why the condition cannot or should not be stabilized) and has provided care to prevent or treat existing PU/PIs (including pertinent, routine, lesser aggressive approaches, such as, cleaning, turning, repositioning).[1,2]

Question 3: If terminal how do you document accordingly ?
Answer: Please see answer to question 2 

Question 4: Do kennedy ulcers count as hospital acquired? 
Answer: CMS recognizes the that PUs/PIs at the end-of-life may be unavoidable (and thus not hospital acquired). See answer to question 2

References:
[1] CMS State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-State-Operations-Manual.pdf)

- F684 §483.25 Quality of care: "...Kennedy Terminal Ulcers are considered to be pressure ulcers that generally occur at the end of life. For concerns related to Kennedy Terminal Ulcers, refer to F686, §483.25(b) Pressure Ulcers." 
- F686, §483.25(b) Pressure Ulcers:
"...It is important for surveyors to understand that when a facility has implemented individualized approaches for end-of-life care in accordance with the resident’s wishes, the development, continuation, or worsening of a PU/PI may be considered unavoidable. If the facility has implemented appropriate efforts to stabilize the resident’s condition (or indicted why the condition cannot or should not be stabilized) and has provided care to prevent or treat existing PU/PIs (including pertinent, routine, lesser aggressive approaches, such as, cleaning, turning, repositioning), the PU/PI may be considered unavoidable and consistent with regulatory requirements."

Pressure Ulcers/Injuries - Introduction and Assessment
Nov 6, 2019
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