Falls management presents one of the greatest challenges to the long-term care profession. Preventing and managing falls in the facility is difficult enough without adding the increased complication of QM data that might not accurately reflect the true facility percentage of falls. The current national average on Nursing Home Compare for the Falls with Major Injury Quality Measure is 3.4%. This means that for every 1,000 residents, 34 have experienced one or more falls with major injury during the QM target or look-back period. Tracking and trending of falls would need to investigate if there is any identified change in fall patterns, especially since the current pandemic has resulted in less rehabilitation and increased isolation for residents. However, another important question we need to ask, is everyone coding these falls correctly on the MDS?

The Falls with Major Injury QM reports the percent of long-stay residents who have experienced one or more falls with major injury reported in the target period or look-back period. The look-back scan used for this QM is 275 days, and it comes from coding MDS item J1900C as a 1 or a 2 (one, or 2 or more falls with major injury). It’s important to be sure the CMS definition of a fall is understood and accurately applied. The RAI manual defines a fall as “an unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall, no matter whether it occurred at home, while out in the community, in an acute hospital or a nursing home.” CMS also includes the “intercepted fall” in the fall definition. This is “when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person”.

What many do not realize is the CMS definition goes on to clarify that “Falls are not a result of an overwhelming external force (e.g., a resident pushes another resident)”. This would also include a resident pushing something into another resident (an overwhelming external force) that causes them to fall. Therefore, if a resident pushes another resident causing them to fall, or pushes something into them causing them to fall, these would not be counted as a fall on the MDS.

Another area of significant confusion involves falls that occur during therapeutic interventions. In the RAI manual section J1900 instructions “CMS understands that challenging a resident’s balance and training him/her to recover from a loss of balance is an intentional therapeutic intervention and does not consider anticipated losses of balance that occur during supervised therapeutic interventions as intercepted falls.” If a resident would fall while working with therapy during balance training, again this would not be counted as a fall on the MDS.

The final definition we must be sure to understand for accurate coding of falls on the MDS, and accurate QM calculation is the definition of “major injury”. CMS defines that this type of injury “includes bone fractures, joint dislocations, closed head injuries with altered consciousness”, and a “subdural hematoma”. While other types of injures, such as lacerations or hematomas, may appear “major” in appearance, they are not included in this fall category.

Falls management tests our teams’ assessment and critical thinking skills each and every day. We must make sure that accurate coding of falls helps us to pass the Falls with Major Injury QM test with flying colors.

Questions to ask as you review your facility Fall Prevention & Management Program:

      • Does your fall risk assessment consider common risk factors such as vision impairment, foot/ankle disorders, medications, gait and balance problems and the fear of falling? Strong care plan interventions begin with effective assessment of each individual’s potential intrinsic and extrinsic risk factors.
      • Do care plans tie to individual risk factors? Are care planned interventions consistently carried out by staff? Does documentation reflect the success or failure of particular intervention trials? Are interventions updated to address new falls that occur based on root cause analysis?
      • How are changes in interventions being communicated: to the staff, resident, and resident representative?  Are staff reviewing these in shift change reports?
      • Is the environment formally monitored for potential hazards such as tripping hazards and obstacles? How are staff trained to recognize environmental issues that may contribute to a particular resident’s fall risk? For example, it is important to recognize and address improper use of assistive devices, improper bed height, inadequate lighting, and the presence of uneven surfaces such as occur with flooring transitions.
      • Is cognitive ability considered in the fall risk management plan? Residents with dementia will likely not be successful with the intervention “Remind to use the call light”. Formal cognitive assessment and dementia staging is often helpful in determining interventions most likely to be successful for each individual based on their remaining cognitive abilities.
      • How are fall events managed? Is there a team huddle to assess root causes of the fall event and put immediate interventions in place? A commitment to complete a thorough fall scene investigation is an important step in gathering the information necessary to determine the root cause(s) and prevent the same or similar falls in the future.
      • Review the structure of your falls committee and how the QAPI activities related to falls are going. How effective are follow up investigations? What performance improvement projects have been conducted and were they successful? Once the basics for fall assessment, fall management, and fall interventions/response are going smoothly, consider addressing facility-specific identified improvement opportunity areas such as sleep deprivation, alarm use, rounding for needs, physical performance programs (e.g. posture, balance, strength, positioning), activities programming, etc.
      • Assess the potential to benefit from Therapy or a Restorative Nursing Program. For example, residents with foot/ankle symptoms including neuropathy, impaired range of motion and circulatory impairment may benefit from an individualized maintenance program and assessment of footwear.


Contact Proactive to request support services including training, falls program development and consultation related to reducing falls and improving fall-related Quality Measures.


Blog by Janine Lehman, RN, RAC-CT, CLNC, Proactive Medical Review

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