Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P

IRF-PAI Training Manual

SECTION IV

MEDICAL NEEDS/QUALITY INDICATORS

Quality Indicators

Pressure Ulcer

The observation period for the Pressure Ulcer items (items 48A through 50D) is three calendar days.

Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage.

48A. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.

Number of Stage 2 pressure ulcers

Admission _____________ Discharge ______________

48B. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Number of Stage 3 pressure ulcers

Admission _____________ Discharge ______________

48C. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.

Number of Stage 4 pressure ulcers

Admission _____________ Discharge ______________

Worsening in Pressure Ulcer Status Since Admission

Indicate the number of current pressure ulcers that were not present or were at a lesser stage at admission. If no current pressure ulcer at a given stage, enter 0.

49A. Stage 2.

Enter Number: _____________

49B. Stage 3.

Enter Number: _____________

49C. Stage 4.

Enter Number: _____________

Healed Pressure Ulcers.

Were pressure ulcers present on admission? (Score item 50A as 0 - No or 1 – Yes)

50A. Admission _________

Indicate the number of pressure ulcers that were noted on admission that have completely closed (resurfaced with epithelium). If no healed pressure ulcer at a given stage since admission, enter 0.

(Code only if item 50A is 1 – yes)

50B. Stage 2

Enter Number ________

50C. Stage 3

Enter Number _________

50D. Stage 4

Enter Number _________

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