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The Sun Top Nursing Home is currently a 100-bed facility located in a two-story building. Due to demand, two additional two-story buildings will be opening within the next two years. When completed, the units will be 1 North, 2 North, 1 East, 2 East, 1 West, and 2 West.

The Centers for Medicare & Medicaid Services (CMS) implements quality initiatives to assure quality health care for Medicare beneficiaries through accountability and public disclosure. CMS uses quality measures in its various quality initiatives that include quality improvement, pay for reporting, and public reporting. Quality measures are tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include effective, safe, efficient, patient-centered, equitable, and timely care.

Long Stay Quality Measures

· Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)

· Percent of Residents who Self-Report Moderate to Severe Pain (Long Stay)

· Percent of High-Risk Residents with Pressure Ulcers (Long Stay)

· Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine (Long Stay)

· Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine (Long Stay)

· Percent of Residents with a Urinary Tract Infection (Long Stay)

· Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder (Long Stay)

· Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (Long Stay)

· Percent of Residents Who Were Physically Restrained (Long Stay)

· Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long Stay)

· Percent of Residents Who Lose Too Much Weight (Long Stay)

· Percent of Residents Who Have Depressive Symptoms (Long Stay)

· Percent of Long-Stay Residents Who Received An Antipsychotic Medication. (RTI International, 2019)

The Chief Nursing Officer/Director of Quality Improvement is concerned that as the facility expands, the Centers for Medicare & Medicaid Services (CMS) Long Stay Quality Measures results will reflect negatively upon the facility. The quality of care of the facility is good, but documentation in the MDS 3.0 is often with errors or omissions. The Chief Nursing Officer requested assistance in comparing the MDS 3.0 documentation with information abstracted after the resident’s discharge in preparation to a new training initiative for the staff hiring anticipated with the building expansion. For this assignment,

· Review the quality indicators and select two of the quality measures.

· Create a proposal to compare and contrast the MDS 3.0 findings with the information abstracted after the resident’s discharge.

· Determine the number of resident cases to be used in the study.

· Identify the codes abstracted from the residents’ health records related to each selected quality measure.

· Identify data that is not currently abstracted from the health records related to each selected quality measure.

· Outline the end of study report format.