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

CBE ID
0678
1.4 Project
Patient Safety
Endorsement Status
Endorsement Removed
1.1 New or Maintenance
Maintenance
Previous Endorsement Cycle
Fall 2018
Is Under Review
No
1.3 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.

    • 1.14 Numerator

      SNF/NH Numerator: The numerator is the number of short-stay residents with an MDS assessment during the selected time window who have one or more Stage 2-4 pressure ulcer(s), that are new or worsened, based on examination of all assessments in a resident’s episode for reports of Stage 2-4 pressure ulcer(s) that were not present or were at a lesser stage on prior assessment.

      LTCH Numerator: The numerator is the number of stays for which the discharge assessment indicates one or more new or worsened Stage 2-4 pressure ulcer(s) compared to admission.

      IRF Numerator: The numerator is the number of stays for which the IRF-PAI indicates one or more Stage 2-4 pressure ulcer(s) that are new or worsened at discharge compared to admission.

    • 1.15 Denominator

      SNF/NH Denominator: The denominator is the number of short-stay residents with one or more MDS assessments that are eligible for a look-back scan (except those with exclusions).
      Assessment types include: an admission, quarterly, annual, significant change/correction OBRA assessment; or a PPS 5-, 14-, 30-, 60-, or 90-day, or discharge with or without return anticipated; or SNF PPS Part A Discharge Assessment.

      LTCH Denominator: The denominator is the number of patient stays with both an admission and discharge LTCH CARE Data Set assessment, except those who meet the exclusion criteria.

      IRF Denominator: The denominator is the number of Medicare patient stays* (Part A and Medicare Advantage) with an IRF-PAI assessment, except those who meet the exclusion criteria.
      *IRF-PAI data are submitted for Medicare patients (Part A and Medicare Advantage) only.

    • Exclusions

      SNF/NH Denominator Exclusions:
      1. Short-stay residents are excluded if none of the assessments that are included in the look-back scan has a usable response for items indicating the presence of new or worsened Stage 2, 3, or 4 pressure ulcer(s) since the prior assessment.

      2. Death in facility tracking records are excluded from measure calculations.

      LTCH Denominator Exclusions:
      1. Patient stay is excluded if data on new or worsened Stage 2, 3, and 4 pressure ulcer(s) are missing on the planned or unplanned discharge assessment.
      2. Patient stay is excluded if the patient died during the LTCH stay.


      IRF Denominator Exclusions:
      1. Patient stay is excluded if data on new or worsened Stage 2, 3, and 4 pressure ulcer(s) are missing at discharge.
      2. Patient stay is excluded if the patient died during the IRF stay.

    • Most Recent Endorsement Activity
      Measure Retired and Endorsement Removed Patient Safety Fall Cycle 2018
      Initial Endorsement
      Last Updated
      Removal Date
    • Steward
      Centers for Medicare & Medicaid Services
      Steward Organization POC Email
      [email protected]