1. What is the metric?

The Percent of High-Risk Residents With Pressure Ulcers (LS)

  1. What does the metric mean?

    This measure reports the percentage of long-stay, high-risk residents with Stage II-IV or unstageable pressure ulcers.


  1. How do we calculate the metric?

The Numerator is the number of Long-stay residents with a selected target assessment where stage II-IV or unstageable pressure ulcers are present, as indicated by any of the following six conditions:

  1. (M0300B1 = [1, 2, 3, 4, 5, 6, 7, 8, or 9])

  2. (M0300C1 = [1, 2, 3, 4, 5, 6, 7, 8, or 9])

  3. (M0300D1 = [1, 2, 3, 4, 5, 6, 7, 8, or 9])

  4. (M0300E1 = [1, 2, 3, 4, 5, 6, 7, 8, or 9])

  5. (M0300F1 = [1, 2, 3, 4, 5, 6, 7, 8, or 9])

  6. (M0300G1 = [1, 2, 3, 4, 5, 6, 7, 8, or 9])


The Denominator is all long-stay residents with a selected target assessment who meet the definition of high risk, except those with exclusions. Residents are defined as high-risk if they meet one or more of the following three criteria on the target assessment:

  1. Impaired bed mobility or transfer indicated, by either or both of the following: 

    1. Bed mobility, self-performance (G0110A1 = [3, 4, 7, 8]).

    2. Transfer, self-performance (G0110B1 = [3, 4, 7, 8]).

  2. Resident is comatose (B0100 = [1]).

  3. Resident demonstrates malnutrition or is at risk of malnutrition (I5600 = [1]).



Exclusions for this metric include Residents with a target assessment that meets any of the following conditions:

  1. The target assessment is an OBRA Admission Assessment 

  2. The target assessment is a PPS 5-Day Assessment

  3. Resident is not in the numerator

  4. Any of the 6 listed MDS items are incomplete


References 

            MDS 3.0 Quality Measures User’s Manual V15

Page 33, Table 2-13