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
Measure Specs
General Information
Numerator
Residents with pressure ulcers (Stage 1-4) on target assessment (M2a >0 OR I3a-3 =707.0)
Denominator
All residents with a valid target assessment and any one of the following inclusion criteria
1.Impaired in mobility or transfer on the target assessment as indicated by G1a(A) = 3, 4, or 8 OR G1b(A) = 3, 4, or 8.
2. Comatose on the target assessment as indicated by B1 = 1.
3. Suffer malnutrition on the target assessment as indicated by I3a through I3e = 260, 261, 262, 263.0, 263.1, 263.2, 263.8, or 263.9.
Exclusions
Exclusions for both measures:
Residents satisfying any of the following conditions are excluded from all risk groups (high and low, high, and low)—this is 1, with 1, 2, and 3 below being 1.1, 1.2, and 1.3:
1. The target assessment is an admission (AA8a = 01) assessment.
2. The QM did not trigger (resident is not included in the QM numerator) AND the value of M2a is missing on the target assessment.
3. The resident is in a facility with a Chronic Care Admission Sample size of 0 (i.e., there are no admission assessments with AA8a = 01 in the facility over the previous 12 months.
4. The resident does not qualify as high-risk AND the value of G1a(A) or G1b(A) is missing on the target assessment.
5. The resident does not qualify as high-risk AND the Value of B1 is missing on the target assessment.
Public Comments