Skip to main content

Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay)

CBE ID
0678
1.5 Project
Endorsement Status
1.0 New or Maintenance
1.1 Measure Structure
Previous Endorsement Cycle
Is Under Review
No
1.6 Measure Description

This quality measure reports the percent of patients or short-stay residents with Stage 2-4 pressure ulcer(s) that are new or worsened since admission. The measure is based on data from the Minimum Data Set (MDS) 3.0 assessments of
Skilled Nursing Facility (SNF) / nursing home (NH) residents, the Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set for LTCH patients and the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) for Inpatient Rehabilitation Facility (IRF) patients. Data are collected separately in each of the three settings using standardized items that have been harmonized across the MDS, LTCH CARE Data Set, and IRF-PAI. For residents in a SNF/NH, the measure is calculated by examining all assessments during an episode of care for reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage since admission. For patients in LTCHs and IRFs, this measure reports the percent of patients with reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage on admission.
Of note, data collection and measure calculation for this measure is conducted and reported separately for each of the three provider settings and will not be combined across settings.

For SNF/NH residents, this measure is restricted to the short-stay population defined as those who have accumulated 100 or fewer days in the SNF/NH as of the end of the measure time window. In IRFs, this measure is restricted to IRF Medicare (Part A and Medicare Advantage) patients. In LTCHs, this measure includes all patients.

Measure Specs
General Information
1.7 Measure Type
1.3 Electronic Clinical Quality Measure (eCQM)
1.8 Level of Analysis
1.20 Types of Data Sources