MDS Alert

Published on Fri Feb 27, 2004 PDF

Post-Acute Quality Measures

Percent of short-stay residents who had moderate to severe pain (Residents at the 14-day assessment who have moderate pain at least daily OR excruciating pain at any frequency)

Percent of short-stay residents with pressure sores (Residents who develop at least a stage 1 pressure ulcer from the 5-day to the 14-day assessment, or whose pressure ulcer worsened or stayed the same from the 5-day to the 14-day assessment)

Percent of short-stay residents with delirium (Residents at the 14-day assessment who have at least one symptom of delirium that is a departure from their usual functioning)

Chronic-Care Quality Measures

Percent of residents whose need for help with daily activities has increased (Residents with decline in late-loss ADL functioning from prior to target assessment)

Percent of residents who have moderate to severe pain (Residents with moderate pain at least daily or excruciating or horrible pain at any frequency. Admission assessment excluded)

Percent of residents who were physically restrained (Residents who were restrained daily. Admission assessment excluded)

Percent of residents who spent most of their time in bed or in a chair (Residents who are bedfast -- MDS item G6a checked. Admission assessment excluded)

Percent of residents whose ability to move about in and around their room got worse (Residents whose locomotion self-performance declines from the prior to target assessment)

Percent of residents with a urinary tract infection (Residents with UTI coded in Section I. Admission assessment excluded) 

Percent of residents who have become more depressed or anxious (Residents whose Mood Scale Score has increased from the prior to the target assessment)

Percent of high-risk residents who have pressure sores (Residents with any stage pressure ulcer with one or more of three risk factors: malnutrition, comatose, impaired in bed mobility or transfer. Admission assessment excluded)

Percent of low-risk residents who have pressure sores (Residents with any stage pressure ulcer who don't have any of the three risk factors above. Admission assessment excluded)

Percent of low-risk residents who lose control of their bowel or bladder (Residents who are frequently or fully incontinent and who don't qualify as high risk [severe cognitive impairment or totally dependent in mobility ADLs] or have indwelling catheter, ostomy or are comatose. Admission assessment excluded)

Percent of residents who have/had a catheter inserted and left in their bladder (Residents with indwelling catheters. Admission assessment excluded)

Paired Measures:

Percentage of residents with incontinence and indwelling catheters

Percentage of residents with low- and high-risk pressure ulcers

Note: Not all exclusions and covariates are included above. For more information on these and MDS coding for the QMs,  go to "Snapshot Definitions of NHQI Quality Measures, January 2004" at www.cms.hhs.gov/quality/nhqi/Snapshot.pdf.