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Nursing Home/Skilled Nursing Facility

Valid for Measure Submission

Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls

  • This is a clinical process measure that assesses falls prevention in older adults. The measure has three rates:

    A) Screening for Future Fall Risk:
    Percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 months



    B) Falls Risk Assessment: 
    Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months

    C) Plan of Care for Falls: 

    CBE ID
    0101

Heart Failure: Symptom and Activity Assessment

  • Percentage of patient visits for those patients aged 18 years and older with a diagnosis of heart failure with quantitative results of an evaluation of both current level of activity and clinical symptoms documented

    CBE ID
    0077

High-risk residents with pressure ulcers

  • Percentage of residents with a valid target assessment and one of the following inclusion criteria: 1.Impaired in mobility or transfer on the target assessment
    2. Comatose on the target assessment
    3. Suffer malnutrition on the target assessment who have pressure ulcers

    CBE ID
    0198

Hypertension: Blood Pressure Control

  • Percentage of patients aged 18 years and older with a diagnosis of hypertension with a blood pressure <140/90 mm Hg OR patients with a blood pressure >= 140/90 mm Hg and prescribed 2 or more anti-hypertensive medications during the most recent office visit within a 12 month period

    CBE ID
    0013

National Healthcare Safety Network (NHSN) Catheter-associated Urinary Tract Infection (CAUTI) Outcome Measure

  • De.2. Brief description of measure
    Standardized Infection Ratio (SIR) of healthcare-associated, catheter-associated urinary tract infections (CAUTI) will be calculated among patients in the following patient care locations:
    • Intensive Care Units (ICUs) (excluding patients in neonatal ICUs [NICUs: Level II/III and Level III nurseries])
    • Specialty Care Areas (SCAs) - adult and pediatric: long term acute care, bone marrow transplant, acute dialysis, hematology/oncology, and solid organ transplant locations

    CBE ID
    0752

National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome Measure

  • Standardized Infection Ratio (SIR) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in the following patient care locations:
    • Intensive Care Units (ICUs)
    • Specialty Care Areas (SCAs) - adult and pediatric: long term acute care, bone marrow transplant, acute dialysis, hematology/oncology, and solid organ transplant locations

    CBE ID
    0754

Nurse staffing hours - 4 parts

  • Percentage of daily work in hours by the entire group of nurses or nursing assistants spent tending to residents

    CBE ID
    0190