2021 HCPR17: Pressure Ulcers – Risk Assessment and Plan of Care

Measure Description

Percentage of Adult Post-acute Facility Patients That Had a Risk Assessment for Pressure Ulcers and a Plan of Care for Pressure Ulcer Prevention/Treatment Completed

Denominator

• Adult patients aged ≥ 18 years evaluated by the Eligible Professional in the Post-acute Facility (E/M Codes 99304-99310, 99315, 99316)

Numerator

Adult Post-acute Facility Patients that Had a Risk Assessment for Pressure Ulcers and a Plan of Care for Pressure Ulcer Prevention OR Treatment Documented Definitions

• Pressure ulcer: Localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear.
• Risk assessment:
  • Nationally recognized scale (e.g., Braden Scale or Braden Q Scale)
  • Nutrition
  • Activity and Mobility Limitations
  • History of skin breakdown
  • Cognition
• Plan of care – Prevention:
  • Scheduled skin integrity assessments
  • Minimize friction and shear
  • Minimize pressure with off-loading
  • Manage moisture
  • Maintain adequate nutrition and hydration
• Plan of care – Treatment:
  • Scheduled wound description/staging
  • Etiology of pressure (e.g., dementia, diapering)
  • Body repositioning
  • Nutritional status
  • Bacterial colonization/infection
  • Wound management (e.g., wound dressings, barrier creams, medicated creams, antibiotics, gauze)

Numerator Options

• Performance Met (PRO09): Patients who did have pressure ulcer risk assessment AND a plan of care for pressure ulcer prevention or treatment documented
• Performance Not Met (PRO10): Patients who did not have pressure ulcer risk assessment AND a plan of care for pressure ulcer prevention or treatment documented

Numerator Exclusions

None

NQF ID Number

N/A

NQS Domain

Patient Safety

High Priority Measure

Yes

Includes Telehealth?

Yes

Inverse Measure

No

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be calculated and submitted

1

Risk-Adjusted Status?

No