Unreported Falls in Nursing Homes: OIG Study Findings
In September 2025, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released a concerning report related to a study with findings indicating that falls with major injury were significantly underreported by skilled nursing facilities.
Study Purpose: The intent of the study was to evaluate the reliability of self-reported data related to falls with major injury, which have implications on quality of life as well as financial implications for the Medicare program and its beneficiaries.
MDS assessments and hospital claims for beneficiaries identified as nursing home residents at the time of the fall were evaluated assessing prevalence and outcomes of the falls, resident demographics and risk factors and characteristics of the nursing home.
Study Methodology
The OIG conducted a comprehensive analysis using:
Medicare Claims Data: Hospital claims for July 1, 2022, through June 30, 2023, were used to identify Medicare beneficiaries who were hospitalized due to a fall with major injury during a preceding SNF stay.
Minimum Data Set (MDS) Assessments: When a nursing home resident is discharged a discharge assessment is completed. These required assessments are used to track resident conditions and assess the quality of care provided through quality measures that are publicly reported on care compare.
Data Matching: The identified hospital claims were matched with MDS assessments to determine if the facility accurately reported the falls in compliance with the regulations.
Additional Study Criteria:
- Major Injury was determined by hospital claims data including diagnosis and external cause codes supporting a major injury
- Only Medicare enrolled beneficiaries in the SNF were included in the study
- Falls that occurred outside of the nursing home were excluded
Key Study Findings Reported:
- 42,864 residents experienced a fall with major injury that resulted in hospitalization during the one-year study period
- Over 1900 resulted in a death
- Over $800 million was paid by Medicare and the enrollee as the result for care related to falls with major injury.
- SNFs Failed to report 43% of these falls with major injury on the required MDS assessment.
- For profit, chain and large nursing homes failed to report more often.
- Fall reporting varied by state but was worse among urban facilities.
- Failure to report falls on the MDS assessment leads to inaccurate publicly reported data on care compare, which is a key tool used by consumers in evaluating nursing homes.
- Low fall rates are likely driven by failure to accurately report falls rather than a lower incidence of falls.
- An example was provided of a large nursing home with 13 falls with major injury identified during the one-year period, but only 3 reported on the facilities MDS assessments. Care Compare displayed a 1.3% rating for this measure which was significantly lower than the national average of 3.6%.
- Low fall rates are likely driven by failure to accurately report falls rather than a lower incidence of falls.
- 42,864 residents experienced a fall with major injury that resulted in hospitalization during the one-year study period
Why it matters: OIG Recommendations
- CMS should take steps to ensure the completeness and accuracy of the MDS data used to calculate the QM for falls with major injury.
- CMS should explore whether approaches to improve fall related QMs can be used to improve the accuracy of other nursing home QMs.
What to Expect
As a result of these recommendations SNFs can anticipate increased regulatory focus on the accuracy of the reporting of data used to calculate the nursing quality measures. CMS has indicated the following steps are in place or in the process of implementation:
- Updates to the RAI User’s Manual coding guidance and tips related to falls and fall related injuries to improve consistency of coding
- Enhanced auditing through the SNF QRP/VBP validation program
- Increased regulatory focus related to falls during survey to include reporting facilities with a “pattern” of underreporting fall to the OIG
Recommendations for SNFs:
To address the findings and improve transparency and resident safety, SNFs should consider the following actions:
- Strengthen Fall Reporting Compliance
- Ensure all falls with major injury are coded on the MDS in accordance with the regulatory requirements and RAI manual guidance.
- Conduct internal audits to validate all major injuries are captured and reported.
- Create a culture of safety where reporting incidents is encouraged and supported.
- Be aware of and responsive to the CMS driven initiative to improve fall prevention and reporting
- Attend education and training provided by CMS and/or provider association training related to this topic.
- Respond timely to audit focused validation programs and regulatory requirements.
- Utilize the Validation Program result reports and survey deficiency findings to educate the clinical staff and inform on processes going forward.
- Enhance Staff Education
- Provide ongoing education for staff on fall prevention, injury classification and accurate MDS coding. Check out these helpful training options:
- Utilize case studies with scenarios and compliance consequences within the staff training.
- Utilize a QAPI approach to fall prevention and reporting
- Use internal data to identify trends and root causes.
- Set measure goals for reduction of falls and accurate reporting.
- Strengthen Fall Reporting Compliance
Next Steps: Contact Proactive to learn more about our targeted support for fall prevention systems improvement, fall event response and guidance to reduce risk related to residents with repeated falls. Learn more.
Written By:
Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Senior Consultant
Proactive LTC Consulting
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