Q:
Fall with major injury has triggered under my SNF QRP reports but no fall with major injury was coded on the 5-Day assessment or the PPS Discharge assessment that were submitted. Where did the information pull from?
A:
The SNF QRP measure for falls with major injury derives its data from the MDS (Minimum Data Set) assessments submitted by the facility. Specifically, it is based on MDS Section J1900 (Falls), which asks about falls that occurred since the prior assessment and whether they resulted in major injury (e.g., bone fractures, joint dislocations, closed-head injuries with altered consciousness, or subdural hematomas).
The 5-Day PPS and Part A PPS Discharge assessments are the primary tools for collecting data for the SNF QRP. However, federal assessments required under OBRA rules are typically completed during the same timeframe as a SNF stay, it was decided that these assessments, along with the 5-Day PPS and Part A PPS Discharge assessments, would also contribute to calculating one of the SNF QRP quality measures (QMs): the Application of Percent of Residents Experiencing One or More Falls with Major Injury. This QM uses all qualifying assessments throughout the resident’s entire SNF stay to determine if a fall with major injury has occurred since admission. The process of reviewing these assessments is referred to as a “look-back scan.” Notably, the Falls with Major Injury QM is the only SNF QRP QM that employs this look-back scan process.
If you identify a discrepancy in coding or reporting, you may need to submit a correction request for the affected MDS assessments. Additionally, document all findings and actions taken for compliance purposes.
Written by:
Brandy Hayes, RN, RAC-CT, RAC-CTA
Clinical Consultant
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