Pressure ulcers (bedsores or pressure injuries) are localized areas of damage to the skin and underlying soft tissue, usually over a bony prominence. They result from sustained pressure or pressure combined with shear forces. The development of a pressure ulcer during a patient’s stay indicates potential deficiencies in care quality across various medical settings. These incidents are subject to mandatory reporting to federal agencies like the Centers for Medicare & Medicaid Services (CMS), transforming a clinical event into a performance metric.
Pressure Ulcers as Measures of Healthcare Quality
Pressure ulcers serve as a direct metric for patient safety and the effectiveness of preventative care protocols. Measurement focuses on the incidence of these injuries, meaning the ulcer must have developed after the patient was admitted. Severe types of pressure ulcers are designated as Hospital-Acquired Conditions (HACs), signaling that they should have been preventable with appropriate care.
The staging of the injury determines its inclusion in quality measures, with the most severe stages carrying the greatest weight in the calculations. Specifically, a new or worsened Stage 3, Stage 4, unstageable pressure injury, or deep tissue pressure injury (DTPI) are the primary focus of federal quality reporting programs. The incidence rate of these advanced-stage ulcers contributes to a composite score used by the federal government to assess hospital performance. Mandatory quality reporting is a requirement for facilities seeking reimbursement for patients covered by Medicare and Medicaid.
In the inpatient hospital setting, the pressure ulcer rate is one component of the CMS Patient Safety and Adverse Events Composite (CMS PSI 90) measure. This composite score combines data from multiple patient safety indicators, providing a comprehensive, risk-adjusted measure of patient harm. The focus on Stages 3 and 4 reflects the high cost, morbidity, and general avoidability of these advanced wounds. This tracking system is designed to financially incentivize hospitals to implement robust prevention strategies.
Defining the Reporting Window
The duration a pressure ulcer incident affects a facility’s quality measure score is determined by the regulatory program’s defined look-back period. While the incident is a permanent part of the patient’s record, its influence on the facility’s calculated rate is temporary. The length of this reporting window varies significantly depending on the type of facility.
For Inpatient Prospective Payment System (IPPS) hospitals, the pressure ulcer rate component of the CMS PSI 90 is calculated using a 24-month period of claims data. A single incident contributes to the facility’s calculated rate for the next two years as the look-back window rolls forward. Because the claims data lag the current date, the facility’s current performance is assessed based on data from a prior two-year timeframe.
In Skilled Nursing Facilities (SNFs), pressure ulcer quality measures are calculated using data submitted via the Minimum Data Set (MDS) assessments. These rates track the percentage of residents with new or worsened pressure ulcers. They are calculated using a four-quarter average, reflecting a full 12 months of clinical data. This rolling 12-month period ensures the rate is stable and not overly sensitive to seasonal or short-term variations.
Home Health Agencies (HHAs) follow a similar pattern, with their pressure ulcer quality measure calculated quarterly using a rolling 12 months of data collected through the Outcome and Assessment Information Set (OASIS). In all settings, the pressure ulcer incident remains a data point in the calculation until it falls outside the specified 12-month or 24-month look-back period. Once the incident date is older than the required look-back period, it no longer contributes to the current quality measure rate.
Impact on Public-Facing Facility Ratings
The calculated pressure ulcer rate significantly impacts a facility’s public profile and financial standing, often lasting longer than the initial reporting window. The rate is the input, and the resulting public score is the output, refreshed on a schedule determined by the public reporting system.
For skilled nursing facilities, the pressure ulcer quality measure contributes to the CMS Nursing Home Compare Five-Star Quality Rating System. This system is updated quarterly. A poor pressure ulcer rate based on 12-month data influences the facility’s star rating for the entire quarter until the next refresh. The public rating reflects a past performance window up to a year old, and the negative perception persists for that duration.
Hospitals face financial consequences through the Hospital-Acquired Condition Reduction Program (HACRP), which uses the CMS PSI 90 score, including the pressure ulcer component, to determine penalties. If a hospital ranks in the worst-performing quartile nationally, it receives a 1% reduction in its overall Medicare payments. This financial penalty is applied for the entire federal fiscal year, running from October 1 to September 30.
The fiscal year penalty means that data collected over the 24-month performance period leads to a financial consequence lasting a full 12-month period. An individual pressure ulcer incident, which fell off the 24-month calculation window after two years, can still indirectly cause a payment reduction that lasts for a third year. This extended consequence highlights the long-term regulatory weight placed on preventing these injuries. Furthermore, the public display of quality measure data on platforms like Care Compare also means the specific rate remains accessible to consumers for a considerable period, reinforcing the extended duration of the public impact.