This measure is based on data from the MDS 3.0 assessment of short-stay nursing facility residents and reports the percentage of those short-stay residents who can self-report and who are on a scheduled pain medication regimen at admission (5-day PPS MDS assessment) and who report lower levels of pain on their discharge MDS 3.0 assessment or their 14-day PPS MDS assessment (whichever comes first) when compared with the 5-day PPS MDS assessment.
The numerator is the number of short-stay residents who have a 14-day PPS assessment or discharge assessment (whichever comes first), who can self-report,(MDS 3.0 item J200=1) and who are on a scheduled pain medication regimen (MDS 3.0 item J0100A = 1), reporting a defined reduction in pain when compared to their earlier assessment (a 5-day PPS assessment). Reduced pain is indicated, when compared to the prior assessment, there is a decrease in pain frequency (MDS 3.0 item J0400) or a decrease in pain intensity (as reported in MDS 3.0 item J0600A = 0–10, with 10 being the worst pain you can imagine, or a decrease in the verbal description of pain (MDS 3.0 item J0600B = 1–4, with 4 being very severe, horrible pain).
Denominator
1.15 Denominator
The denominator is the total of all short-stay residents in the nursing facility who have a 5-day PPS MDS 3.0 assessment and either a 14-day PPS MDS 3.0 assessment or a discharge MDS 3.0 assessment (whichever comes first); who have been on a scheduled pain medication regimen (MDS 3.0 item J0100A = 1) and who do not meet the exclusion criteria.
Exclusions
Exclusions
A resident is excluded from the denominator if there are missing data in the relevant MDS questions.
If the short-stay facility has fewer than 20 residents in the sample, they are excluded from public reporting because of small sample size.
Measure Record
Most Recent Endorsement Activity
Measure Retired and Endorsement Removed National Voluntary Consensus Standards for Nursing Homes 2010
Public Comments