There are both short and long stay Quality Measures (QM) for Pressure Ulcer/Injury.
The short stay measure looks at the percentage of patients with Pressure Ulcers that are new or worsened. This measure impacts the Quality Reporting Program. The numerator for the short stay measure is the number of Medicare Part A SNF stays for which the discharge assessment indicates one or more new or worsened Stage 2– 4 pressure ulcers or unstageable pressure ulcers compared to admission. The denominator is the number of Medicare Part A SNF stays in the selected timeframe for SNF residents ending during the selected time window, except for those that meet the exclusion criteria. Exclusion criteria for this includes:
· Missing data on new or worsened Stage 2, 3, 4, and unstageable pressure ulcers, including deep tissue injuries.
· Resident died during SNF stay.
This measure applies to Type 1 SNF Stays only, which is a stay with a matched pair of PPS 5-Day and Discharge Assessment and NO Death in Facility Tracking Record. This short stay measure is also risk adjusted based on co-variates related to functional mobility admission performance, bowel incontinence, peripheral vascular disease/peripheral arterial disease or diabetes mellitus, and low body mass index.
The long stay measure captures the percentage of residents with a stage 2 – 4 or unstageable pressure ulcer/injury. This measure impacts Care Compare and Five Star, although it is currently frozen on Care Compare until January 2025. This measure may also impact Medicaid reimbursement dependent on the State your facility is in. The numerator for the long stay measure is all residents with a selected target assessment that meets any of the following six conditions:
The denominator for this long stay measure is all long stay residents with a selected target assessment, except those with exclusions. Exclusions for this measure include:
· Target assessment is an OBRA Admission Assessment or a PPS 5-Day Assessment
· Resident is not included in the numerator and a dash is entered in Section M0300B1 –M0300G1.
Covariates for risk adjustment for this measure include those noted above as well as some additional items on the target assessment:
· Impaired functional mobility with lying to sitting on side of bed (GG0170C)
· Bowel incontinence (H0400)
· Diabetes Mellitus, Peripheral Vascular Disease, or Peripheral Artery Disease (I0900 orI2900)
· Low body mass index
· Malnutrition (I5600)
· Dehydration (J1550C)
· Septicemia, Pneumonia, Urinary Tract Infection, or Multidrug Resistant Organism (I2100, I2000, I2300, or I1700)
· Moisture Associated Skin Damage (M1040H)
· Hospice Care (O0110K1b)
State Surveyors use the Pressure Ulcer/Injury Critical Element Pathway when reviewing facility performance with those patients/residents. Aspects reviewed include comprehensive assessments focused on Section C, GG, H, J, K, and M of the MDS, Physician orders, pertinent diagnoses, and care planning. Staff assistance and interventions are observed across shifts, and interviews are conducted across shifts with residents, their representatives, and family and with staff. Failure to comply can lead to various F-tags.