This measure reports the percentage of low risk, long-stay residents who have had an indwelling catheter in the last seven days prior to the assessment reference date on the target assessment. In this case, low-risk refers to residents who do not have preexisting conditions, such as neurogenic bladder or obstructive uropathy, which predispose catheter use. This measure is based on data from the Minimum Data Set (MDS) 3.0 OBRA, PPS, and/or discharge assessments during the selected quarter. Long-stay nursing home residents are identified as those who have had 101 or more cumulative days of nursing home care.
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1.14 Numerator
The numerator is the number of long-stay nursing home residents in the denominator sample with an episode during the selected quarter with a target assessment that indicates the use of indwelling catheters within the last seven days.
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1.15 Denominator
The denominator includes all long-stay residents in the nursing home who have an episode during the selected quarter with a qualifying target assessment (OBRA, PPS, or discharge assessment) and who do not meet the exclusion criteria.
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Exclusions
The denominator exclusion criteria for this quality measure are as follows: 1) The target assessment is an admission assessment, a PPS 5-day assessment or a PPS readmission/return assessment; 2) The target assessment indicates that indwelling catheter status is missing; 3) The target assessment indicates neurogenic bladder or neurogenic bladder status is missing; or 4) The target assessment indicates obstructive uropathy or obstructive uropathy status is missing.
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1.13a Data dictionary not attachedNo
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Most Recent Endorsement ActivityEndorsed Patient Safety Fall Cycle 2019Initial EndorsementLast Updated
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StewardCenters for Medicare & Medicaid ServicesSteward Organization POC EmailSteward Organization Copyright
This is not applicable.
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Risk AdjustmentRisk adjustment approachOffRisk adjustment approachOffConceptual model for risk adjustmentOffConceptual model for risk adjustmentOff
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6.1.2 Current or Planned Use(s)
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Planned Use
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