Toward a National Health Information Infrastructure: A Key Strategy for Improving Quality in Long-Term Care. APPENDIX C. Examples of MDS-Derived Quality Indicators

Prevalence of Stage 1-4 Pressure Ulcer
Numerator Residents with pressure ulcers (Stage 1-4) on most recent assessment.
Denominator All residents on most recent assessment.
MDS 2.0 Quarterly Variable Definition Pressure ulcer (M2a > 0, or 13 = ICD-9 CM 707.0)
Risk Adjustment High Risk:
  • Impaired transfer or bed mobility (G1a or b = 3 or 4-Box A)
  • OR comatose (B1 = 1)
  • OR malnutrition (13 = ICD-9 CM 260,261, 262, 263.0, 263.1, 263.2, 263.8, or 263.9)
  • OR end stage disease (J5c is checked) most recent assessment
Low Risk:
  • All others at most recent assessment.

 

Prevalence of Bowel or Bladder Incontinence
Numerator Residents who were frequently incontinent or incontinent on most recent assessment.
Denominator
  • All residents, except as noted in exclusion.
  • Exclude: Residents who are comatose residents (B1 = 1)
       OR have indwelling catheter (H3d is checked)
       OR have an ostomy (H3i is checked) at most recent assessment
MDS 2.0 Quarterly Variable Definition
  • Bladder incontinence (H1b = 3 or 4)
  • Bowel incontinence (H1a = 3 or 4)
Risk Adjustment High Risk:
  • Severe cognitive impairment AND short-term memory problems (B4 = 3 and B2a = 1)
  • OR Totally ADL dependent in mobility ADLs (G1a, b, e-Box A self- performance = 4 in all areas) at most recent assessment
Low Risk:
  • All others at most recent assessment.

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