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Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (Long Stay)

CBE ID
0686
Endorsement Status
1.1 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Fall 2025
1.3 Measure Description

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.

        • 1.5 Measure Type
          1.7 Electronic Clinical Quality Measure (eCQM)
          1.8 Level Of Analysis
        • 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.

        • 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.

        • 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.

        • 1.13a Data dictionary not attached
          No
        • Most Recent Endorsement Activity
          Endorsed Patient Safety Fall Cycle 2019
          Initial Endorsement
          Last Updated
        • Steward
          Centers for Medicare & Medicaid Services
          Steward Organization POC Email
          Steward Organization Copyright

          This is not applicable.

              • Risk Adjustment
                Risk adjustment approach
                Off
                Risk adjustment approach
                Off
                Conceptual model for risk adjustment
                Off
                Conceptual model for risk adjustment
                Off