From Risk to Results: Pressure Ulcer QM Improvement

From Risk to Results: Pressure Ulcer QM Improvement

Pressure Ulcer and injury Quality Measures (QMs) are no longer just indicators of care; they are performance drivers that directly impact your Five-Star rating, public reporting, and reimbursement. Yet many facilities struggle to achieve targets in this measure because they lack a structured approach to QM improvement. Improving pressure ulcer and injury Quality Measures requires more than prevention – it requires precision, consistency, and accountability across systems.

Improvement begins by understanding what the measure is capturing.

 

Long-Stay QM

Percent of Residents with Pressure Ulcers/Injuries

• • Includes all residents with 101 or more cumulative days in the facility (CDIF)
  • Captures Stage 2-4, unstageable, and deep tissue injuries

Improvement Focus: Reduce overall prevalence of pressure ulcers/injuries across the entire long-stay population – not just “high-risk” residents.

 

Short-Stay QM

Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

• • Applies to Medicare Part A stays with 100 or fewer CDIF
  • Measures new or worsened pressure injuries
  • Impacts SNF QRP compliance and reimbursement

Improvement Focus: Prevent new injuries and avoid worsening of wounds present on admission.

 

A Systems-Focused Approach to QM Improvement

It’s important to recognize why some well-intentioned improvement efforts fail. Often, facilities rely on reactive wound care rather than strong systems of prevention. This can include poor documentation of present-on-admission (POA) status or a lack of coordination between nursing, therapy, and dietary, leading to deteriorating wounds or new wounds developing. Couple that with inconsistent or inaccurate MDS coding in Section M, and you’ve got a QM disaster. Improvement requires addressing these issues and not just reinforcing basic interventions.

1. Know your population. For long-stay residents, everyone counts.
   • Audit your trigger list weekly (Stage 2-4, DTIs, unstageable)
   • Identify trends by unit, diagnosis (e.g., diabetes, vascular disease), and functional status

High-performing facilities track who is at risk before they trigger the QM

 

2. Strengthen admission processes. This is one of biggest opportunities for short-stay improvement.
   • Complete a comprehensive skin assessment within 24 hours
   • Clearly document stage, location, description, and POA status
   • Take and maintain wound photos per policy
   • Ensure MDS coding reflects clinical documentation

If it’s not documented on admission, it can become a “new” pressure injury later.

 

3. Standardize early intervention protocols. The goal is reliability, not just knowledge.
   • Create protocols for low, moderate, and high-risk residents, and incorporate personalized preventative measures.
     • Repositioning schedules (individualized, not generic)
     • Support surfaces (mattress, cushions)
     • Incontinence management
     • Therapy or Restorative Nursing referrals
     • Moisture control
     • Hydration monitoring and protein supplementation when indicated

 

4. Emphasize the importance of weekly skin rounds. These rounds should be a data-driven intervention tool and not just another routine task.
   • Include Nursing leadership, wound/treatment nurse, Therapy, Dietary (as needed)
   • Review at-risk residents and not just those with current wounds. Monitor for declines in functional status and focus on early identification of weight loss and malnutrition risk.
   • Monitor wounds for improvement or deterioration, and any new areas of concern.

Tie findings directly to QM tracking and follow-up actions.

 

5. Ensure MDS accuracy – your QMs depend on it! Even strong clinical care can result in poor QM performance if coding is off. High-risk areas for error:
   • Incorrect staging
   • Missing DTIs
   • Misclassification of unstageable wounds
   • Failure to capture worsening

 

6. Use data now, not retroactively. Waiting for quarterly or monthly reports is too late. Internally track:
   • New pressure injuries
   • Worsening cases
   • Unit-level trends
   • Staff compliance with repositioning and care plans

Facilities that improve QMs review data in real time and act quickly.

 

Achieving Lasting Results

Improving pressure ulcer/injury QMs is about doing the right things consistently across every resident every shift. Facilities that see sustained improvement treat pressure injury prevention as a system, not a task. Integrate clinical care, MDS accuracy, and data monitoring, and hold teams accountable through structured processes.

 

 

Next Steps:

1. Dive deeper into this topic when you join Proactive April 29^th for “Below the Surface: Exploring the Pressure Ulcer QM” as part of the Quality Measures Deep Dive series.
2. Contact us for Clinical Nurse Consulting and MDS Support that supports effective systems, staff development and Quality Measure outcomes

 

 

 

Written By:

 

 

Eleisha Wilkes, RN, GERO-BC, RAC-CT, DNS-CT

Senior Consultant

Proactive LTC Consulting