Percentage of residents with a valid target assessment and one of the following inclusion criteria: 1.Impaired in mobility or transfer on the target assessment
2. Comatose on the target assessment
3. Suffer malnutrition on the target assessment who have pressure ulcers
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.8 Level Of Analysis1.9 Care Setting1.20 Testing Data Sources
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1.14 Numerator
Residents with pressure ulcers (Stage 1-4) on target assessment (M2a >0 OR I3a-3 =707.0)
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1.15 Denominator
All residents with a valid target assessment and any one of the following inclusion criteria
1.Impaired in mobility or transfer on the target assessment as indicated by G1a(A) = 3, 4, or 8 OR G1b(A) = 3, 4, or 8.
2. Comatose on the target assessment as indicated by B1 = 1.
3. Suffer malnutrition on the target assessment as indicated by I3a through I3e = 260, 261, 262, 263.0, 263.1, 263.2, 263.8, or 263.9.
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Exclusions
Exclusions for both measures:
Residents satisfying any of the following conditions are excluded from all risk groups (high and low, high, and low)—this is 1, with 1, 2, and 3 below being 1.1, 1.2, and 1.3:
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 M2a is missing on the target assessment.
3. The resident is in a facility with a Chronic Care Admission Sample size of 0 (i.e., there are no admission assessments with AA8a = 01 in the facility over the previous 12 months.
4. The resident does not qualify as high-risk AND the value of G1a(A) or G1b(A) is missing on the target assessment.
5. The resident does not qualify as high-risk AND the Value of B1 is missing on the target assessment.
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Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed Nursing Homes- 2004Initial EndorsementLast UpdatedRemoval Date
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StewardCenters for Medicare & Medicaid Services
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Risk Adjustment
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