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Date: September, 2013


Evanston, Illinois...DM Systems, Inc., manufacturers of Heelift® Glide and Heelift® Suspension Boot, has published a new white paper positing that the CMS categorization of pressure ulcers should be reevaluated.

The Centers for Medicare and Medicaid Services (CMS) defined "never events" in 2008 as issues that "cause serious injury or death to beneficiaries and result in unnecessary costs to Medicare and Medicaid due to the need to treat the consequences of the errors." Pressure ulcers were included in the list of medical issues that were defined as "never events." Enforcement of penalization surrounding "never events" went into effect in October 2008.

Since 2008, new research has surfaced, according to DM Systems, that points to the fact that many pressure ulcer cases are the result of issues beyond the direct control of a facility. "As we learn more about the role of microclimate, comorbidities, and end-of-life skin breakdown, the categorization of pressure ulcers as "never events" increasingly calls for a reevaluation of the established protocol," said Dr. Denis Drennan, MD., DM Systems founder and author of the white paper.

"While there are certainly numerous cases in which pressure ulcers developed as a result of inadequate facility care, scientific evidence is beginning to show that in other cases, facilities are being punished unjustly," Drennan continued.

In May 2013, CMS showed indications that the organization may already be reevaluating "never events." In the CMS LTCH Quality Reporting Program Manual due to go into effect in 2014, the CMS notes:

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 [Terminal] 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.

This is a change for CMS, which previously instructed facilities to code Kennedy Terminal Ulcers as pressure ulcers and hence as "never events."

For more information regarding why the categorization of pressure ulcers as "never events" should be reconsidered, download the DM Systems white paper titled, "Striving for Seldom, Hoping for Never: The Classification of Pressure Ulcers as 'Never Events,'" at

Founded in 1979, DM Systems is committed to quality outcomes across the continuum of care with innovative products developed by orthopedic surgeons to reduce wound prevalence while saving time and money. Other products include the Heelift® Glide, Heelift® Suspension Boot, Heelift® AFO, and HeelSafe™ DVT Hose.

Visit or call 847-328-9540 for more information on the full line of products available from DM Systems.


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