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
This measure is based on data from MDS 3.0 assessments of nursing home residents. Either a resident interview measure or a staff assessment measure will be reported. The preferred version is the resident interview measure. The resident interview measure will be used unless either there are three or more missing sub-items needed for calculation or the resident is rarely or never understood, in which cases the staff assessment measure will be calculated and used. These measures use those questions in MDS 3.0 that comprise the Patient Health Questionnaire (PHQ-9) depression instrument.
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.
This measure reports the percentage of long-stay nursing home residents with a target Minimum Data Set (MDS) assessment (OBRA, PPS, Discharge) that indicates a weight loss of 5% or more of the baseline weight in the last 30 days or 10% or more of the baseline weight in the last 6 months, which is not a result of a physician-prescribed weight-loss regimen. The baseline weight is the resident’s weight closest to 30 or 180 days before the date of the target assessment. Long-stay residents are identified as residents who have had at least 101 cumulative days of nursing facility care.
This measure reports the percentage of long-stay residents in a nursing facility, who reported almost constant or frequent pain, and at least one episode of moderate to severe pain, or any very severe/horrible pain in the 5 days prior to the target assessment. This measure is based on data from the Minimum Data Set (MDS 3.0) OBRA, PPS, and/or discharge assessments during the selected quarter. This measure is risk-adjusted for resident cognitive status. Long-stay nursing facility residents are identified as those who have had 101 or more cumulative days of nursing facility care.
This measure reports the percentage of short-stay residents in a nursing facility, who reported almost constant or frequent pain, and at least one episode of moderate to severe pain, or any very severe/horrible pain in the 5 days prior to the target assessment. This measure is based on data from the Minimum Data Set (MDS 3.0) OBRA, PPS, and/or discharge assessments during the selected quarter. Short-stay nursing facility residents are identified as those who have had 100 or fewer cumulative days of nursing facility care.
The measure reports the percentage of short-stay residents or patients who are assessed and appropriately given the seasonal influenza vaccine during the most recently-completed influenza season. The influenza vaccination season (IVS) is defined as beginning on October 1, or when the vaccine first becomes available*, and ends on March 31 of the following year. This measure is based on the NQF´s National Voluntary Standards for Influenza and Pneumococcal Immunizations.
The measure reports the percentage of all long-stay residents who were physically restrained daily during the 7 days prior to the target MDS 3.0 assessment (OBRA, PPS or discharge) during their episode of nursing home care ending in the target quarter (3-month period). Long-stay residents are identified as residents who have had at least 101 cumulative days of nursing facility care.
This measure, based on data from the Minimum Data Set (MDS) 3.0 assessment of long-stay nursing facility residents, estimates the percentage of long-stay residents in a nursing facility whose need for assistance with late-loss Activities of Daily Living (ADLs), as reported in the target assessment, increased when compared with a prior assessment. The four late-loss ADLs are: bed mobility, transfer, eating, and toilet use.
This measure reports the percentage of long-stay residents in a nursing home who have a urinary tract infection in the 30 days prior to the target assessment. 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.