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281. Table 19F: HCBS Population Ages 18-64 Without I/DD or SMI | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19f.html
     March 01, 2023 - 5,990 6,632 Composite: ACSC Overall 23,094 19,763 20,681 21,282 21,204 19,420 Pressure … Ulcer 6,082 4,303 4,919 4,872 4,765 5,535 Injurious Falls 173 119 141 130 … 5,861 6,673 6,037 6,455 Composite: ACSC Overall 20,343 22,153 21,427 18,076 Pressure … Ulcer 4,499 5,846 4,870 5,072 Injurious Falls 140 131 131 168 Notes

282. Table 19G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19g.html
     March 01, 2023 - 12,136 Composite: ACSC Overall 32,463 23,973 25,306 28,599 25,757 29,466 Pressure … Ulcer 4,845 3,916 4,034 4,473 4,279 3,822 Injurious Falls 694 450 520 525 … 12,380 10,227 12,540 Composite: ACSC Overall 24,470 31,390 25,983 29,126 Pressure … Ulcer 4,169 4,242 4,328 3,449 Injurious Falls 498 580 497 653 Notes

283. Table 19E: SMI Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19e.html
     March 01, 2023 - 6,924 7,208 Composite: ACSC Overall 20,218 17,976 20,084 17,046 19,215 17,075 Pressure … Ulcer 3,124 2,492 3,084 2,232 2,819 2,301 Injurious Falls 297 218 268 212 … 6,471 8,020 7,037 6,881 Composite: ACSC Overall 17,757 20,393 19,476 16,171 Pressure … Ulcer 2,658 2,731 2,846 2,191 Injurious Falls 239 247 236 260 Notes

284. Table 19D: I/DD Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19d.html
     March 01, 2023 - 3,685 2,830 Composite: ACSC Overall 6,401 5,144 6,083 4,903 6,049 4,408 Pressure … Ulcer 1,887 1,225 1,703 1,115 1,573 1,084 Injurious Falls 88 67 77 69 79 … 3,503 3,242 3,720 2,668 Composite: ACSC Overall 5,768 5,111 6,087 4,163 Pressure … Ulcer 1,543 1,223 1,589 999 Injurious Falls 77 67 77 63 Notes:  

285. Table 19C: Medicaid-Only HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19c.html
     March 01, 2023 - 4,435 3,912 Composite: ACSC Overall 14,847 12,685 13,750 12,591 14,039 10,413 Pressure … Ulcer 3,144 1,922 2,311 2,203 2,306 2,125 Injurious Falls 114 46 72 55 58 … 4,284 4,429 4,470 3,725 Composite: ACSC Overall 13,151 13,631 14,134 9,746 Pressure … Ulcer 2,071 2,713 2,345 1,945 Injurious Falls 68 59 59 92 Notes:  

286. Table 19B: Dually Eligible HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19b.html
     March 01, 2023 - 8,456 8,118 Composite: ACSC Overall 25,741 19,330 21,845 20,450 21,888 19,402 Pressure … Ulcer 4,659 3,573 4,127 3,570 4,133 3,186 Injurious Falls 476 335 399 346 … 8,162 8,798 8,469 8,012 Composite: ACSC Overall 20,856 22,154 22,042 18,402 Pressure … Ulcer 4,014 3,688 4,171 2,882 Injurious Falls 384 365 381 366 Notes

287. Table 19A: National HCBS Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19.html
     March 01, 2023 - 7,387 7,164 Composite: ACSC Overall 23,095 17,584 19,743 18,467 19,802 17,363 Pressure … Ulcer 4,291 3,139 3,655 3,225 3,647 2,945 Injurious Falls 388 259 314 272 … 7,138 7,741 7,427 6,977 Composite: ACSC Overall 18,821 20,092 19,980 16,312 Pressure … Ulcer 3,501 3,452 3,695 2,655 Injurious Falls 301 291 297 299 Notes

288. Table 11: Outcome Indicators by Use of Selected Home and Community-Based Services Medicaid State Plan Services, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab11.html
     February 01, 2023 - Overall Yes 14,177 28,212 18,788 9,372 No 19,380 19,211 19,521 20,716 Pressure … Ulcer Yes 2,730 11,421 3,150 1,840 No 3,506 3,461 3,696 3,731 Injurious … Composite: ACSC Overall 50,783 40,549 9,972 20,001 18,997 10,923 20,108 19,218 Pressure … Ulcer 12,696 8,204 883 4,475 3,415 1,644 3,729 3,459 Injurious Falls 469

289. Final Progress Report: Safety Outcomes of Obese Residents in US Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/felix-report.pdf
     January 01, 2024 - Being underweight increased the odds of experiencing a fall, fall with injury, or pressure ulcer but … ulcers/ injuries and UTIs. … Association of overweight and obesity with the prevalence and incidence of pressure ulcers: A systematic … The paradox of obesity in pressure ulcers of critically ill patients. … Obesity and pressure ulcers among nursing home residents. Medical Care. 2013;51(6):478-86. 44.

290. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/impmaterials.html
     June 01, 2017 - Section 1: Screening for Hospital Transfer Risk Section 2: Preventable Hospital and ED Visits - Prevention … |___| Confusion/mental status change |___| |___| Any full thickness wound (e.g., pressure … ulcers [Stage II or greater], surgical wound, stasis ulcer) |___| |___| Polypharmacy (15 or … Chronic pressure ulcers Yes |___| No |___| L. … Meeting Hospital/ED Transfer Prevention Discussed (Yes/No) Meeting Chair/Leader Name and Discipline

291. Central Venous Catheter Indications and Alternatives
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-alternatives.pptx
     April 01, 2022 - ulcers Incontinence-associated dermatitis Daily measurement of urine volume Single 24-hour urine sample … Indications11-13 Acute urinary retention Chronic urinary retention Stage III or IV or unstageable pressure … ulcer Urinary incontinence Urine volume measurements Random urine sample collection Management … Guideline for prevention of catheter-associated urinary tract infections 2009. … Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and

292. AHRQ-Funded Patient Safety Project Highlights (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-harms.pdf
     August 01, 2025 - Ulcer Prevention in Nursing Homes 2015–2018 $1,783,070 Purpose: 1) Disseminate the On-Time Pressure … effective pressure ulcer prevention practices. … Key Findings/Impact: A final report was not available; however, the Preventing Pressure Ulcers in Hospitals … : Implement and evaluate the effectiveness of a pressure ulcer module, “On-Time Quality Improvement … rates, in reducing the rate of pressure ulcers among nursing home residents.

293. IQI, PSI, AND PDI RATES GENERATED BY THE AHRQ WINDOWS QI SOFTWARE (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b2b_combo_ratesgenbywin.pdf
     March 01, 2016 - Ulcer Rate 0 0 - 0.00013297 PDI3 PDI #3 Retained Surgical Item/Unretrieved Device Fragment Count 0 … Count 0 - - - PSI2 PSI #2 Death Rate in Low-Mortality DRGs 8 132 0.06060606 0.00028197 PSI3 PSI #3 Pressure … Ulcer Rate 0 47 0 0.00040548 PSI4 PSI #4 DeathRateSurgInpatientswSeriousTreatableComplications 0 0 … PQI92 PQI #92 Prevention Quality Chronic Composite 795 0.00949090839 PSI21 PSI #21 Retained Surgical … Ulcer Rate 0 47 0 0.000832 0 0.000405 0 0.000379 PSI #4 Death Rate among Surgical Inpatients with

294. No More Cauti Preventing Cauti Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/No_More_CAUTI_Preventing_CAUTI_transcript.docx
     May 05, 2015 - Finally, Liz served as a national mentor to 2 fellows in the project protect infection prevention fellowship … Today, we're going to be talking specifically about the education component in your CAUDI prevention … For a lot of people, part of their CAUDI prevention program is not only looking at appropriate indication … Again, this is a good visual of we're not talking about just a little stage 1 or stage 2 pressure ulcer … The catheter itself can actually cause pressure ulcers just as much as incontinence can.

295. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017-ref.html
     May 01, 2023 - Office of Disease Prevention and Health Promotion. … Office of Disease Prevention and Health Promotion. National Action Plan for ADE prevention. … Costs of venous thromboembolism, catheter-associated urinary tract infection, and pressure ulcer. … Pressure ulcers in the United States' inpatient population from 2008 to 2012: results of a retrospective … Marginal hospital cost of surgery-related hospital-acquired pressure ulcers.

296. Addressing Questions Asked by Staff: Chlorhexidine for Bathing (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-chg-bathing.pdf
     March 01, 2022 - Do not wipe the CHG off as this will reduce its infection prevention abilities. … Be especially thorough if there are any nearby wounds, pressure ulcers, or breaks in the skin. … Using the CHG cloths on superficial wounds/stage 1 and 2 decubitus ulcers How should we dispose of

297. Board and Senior Leadership PowerPoint Presentations on the Pediatric Quality Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pdf
     October 01, 2015 - ulcer) • Denominator = population at risk (e.g., hospitalized patients) • Observed rate = numerator … ulcer in any secondary diagnosis field among cases meeting the inclusion and exclusion rules for the … • Several exclusions (e.g., length of stay <5 days, principal diagnosis of pressure ulcer). … An Example: Pressure Ulcer (PDI 02) http://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V45/ … An Example: Pressure Ulcer (PDI 02)� How can the AHRQ PDIs be used in�quality assessment?

298. Declines in Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-decline.pdf
     June 02, 2025 - Infections +CLABSI - Central Line-Associated Bloodstream Infection Falls Obstetric Adverse Events Pressure … Ulcers Surgical Site Infections Ventilator- Associated Pneumonias 0% (Post-op) Venous

299. Technical Interventions To Prevent CAUTI | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/guides/implguide-pt3.html
     October 01, 2015 - Infographic Poster on CAUTI Prevention Appendix L. … ulcers or similarly severe wounds that cannot be kept clear of urinary incontinence despite wound care … Incontinence without a sacral or perineal pressure sore —Urinary catheters should not be routinely placed … ulcers), and deep venous thrombosis. … ulcer, or similarly severe wounds of other types, that cannot be kept clear of urinary incontinence

300. Chartbook on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
     January 01, 2020 - There are no detailed sections for the Perinatal, Pressure Ulcer, or Surgery or Anesthesia EVENT TYPES … No harm was reported for more than one-quarter (18,632 / 73,155; 25.5%) of Pressure Ulcer Incidents … This was unexpected, as pressure ulcers, like HAIs and venous thromboembolism (VTE), result in harm … Ulcer A pressure ulcer that, on admission, was at stage/category III or stage/category IV or was … /category I or stage/category II A pressure ulcer whose most advanced stage is unknown A mucosal