Percentage of residents with a valid target assessment and not qualifying as high risk who frequently lose control of their bowel or bladder
Measure Specs
General Information
Numerator
Residents who were frequently incontinent or fully incontinent on target assessment (H1a=3 or 4, or H1b=3 or 4).
Denominator
All residents with a valid target assessment and not qualifying as high risk.
Exclusions
1.Residents who qualify as high risk are excluded from the denominator: a. Severe cognitive impairment on the target assessment as indicated by B4 = 3 AND B2a = 1; OR
1. b. Totally dependent in mobility ADLs on the target assessment: G1a(A) = 4 or 8 AND G1b(A) = 4 or 8 AND G1e(A) = 4 or 8..
2. Residents satisfying any of the following conditions are excluded from all risk groups (high and low, high, and low):
1. The target assessment is an admission (AA8a = 01) assessment.
2. The QM did not trigger (resident is not included in the QM numerator) AND the value of H1a or H1b is missing on the target assessment.
3.Residents who are comatose (B1=1) or comatose status is unknown (B1=missing) on the target assessment.
4. The resident has an indwelling catheter (H3d = checked) or indwelling catheter status is unknown (H3d=missing) on the target assessment.
5. The resident has an ostomy (H3i = checked) or ostomy status is unknown (H3i=missing) on target assessment.
6. The resident is in a facility with Chronic Care Admission sample =0 (i.e., there are no admission assessments with AA8a=01 in the facility over the previous 12 months.
3. Residents satisfying any of the following conditions are excluded from the low-risk group:
1. The resident does not qualify as high risk and the value of B2a or B4 is missing on the target assessment.
2. The resident does not qualify as high risk and any of the mobility ADLs (G1a(A), G1b(A), and G1e(A)) is missing on the target assessment.
Public Comments