This measure reports the percentage of long-stay, high-risk, residents in a nursing home who have Stage II-IV or unstageable pressure ulcers on a selected target assessment in the target quarter. The long stay nursing home population is defined as residents who have received 101 or more cumulative days of nursing home care by the end of the target assessment period. A nursing home resident is defined as high-risk for pressure ulcer if they meet one or more of the following three criteria:
1. Impaired bed mobility or transfer
2. Comatose
3. Malnourished or at risk of malnutrition
This measure is based on data obtained through the Minimum Data Set (MDS) 3.0 OBRA, PPS, and/or discharge assessments during the selected quarter(s).
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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
The numerator is the number of long-stay residents identified as high-risk with a selected MDS 3.0 target assessment (OBRA quarterly, annual or significant change/correction assessments or discharge assessment with or without return anticipated) in an episode during the selected target quarter reporting one or more Stage II-IV or unstageable pressure ulcer(s) at the time of assessment. . High-risk residents are those who are comatose (B0100 = [1]), or impaired in bed mobility (G0110A1 = [3, 4, 7, 8]) or transfer (G0110B1 = [3, 4, 7, 8]), or either experiencing malnutrition or at risk for malnutrition (I5600 = [1]). Unstageable pressure ulcers are pressure ulcers that are known to be present but are defined as unstageable due to either a non-removable dressing/device (M0300E1 = [1, 2, 3, 4, 5, 6, 7, 8, or 9]), slough or eschar (M0300F1 = [1, 2, 3, 4, 5, 6, 7, 8, or 9]), or a suspected deep tissue injury (M0300G1 = [1, 2, 3, 4, 5, 6, 7, 8, or 9]).
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1.15 Denominator
The denominator includes all long-stay nursing home residents who had a target assessment (ORBA, PPS, or discharge) during the selected quarter who were identified as high risk for pressure ulcer, and who do not meet the exclusion criteria.
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Exclusions
A resident is excluded from the denominator if:
1. The target MDS assessment is an OBRA admission assessment or a PPS 5-day assessment or a PPS readmission/return assessment.
2. The resident did not meet the pressure ulcer conditions for the numerator and any Stage II, III, IV, or unstageable item is missing (M0300B1 = [-] or M0300C1 = [-] or M0300D1 = [-] or M0300E1 = [-] or M0300F1 = [-] or M0300G1 = [-]).
If the facility sample includes fewer than 20 residents, then the facility is excluded from public reporting because of small sample size.
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Most Recent Endorsement ActivityEndorsed Patient Safety Spring Cycle 2021Initial EndorsementLast Updated
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StewardCenters for Medicare & Medicaid ServicesSteward Organization POC EmailSteward Organization Copyright
n/a
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Risk Adjustment
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6.1.2 Current or Planned Use(s)
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