Harmony Healthcare Blog

Quality Measure #8: One or More Falls with Major Injury - Long Stay (Part 1)

Posted by Kathy Monahan on Thu, Oct 06, 2016

Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

Steps to Better Understand Major Falls with Injury

Root Cause Analysis

nursinghomefall.jpgThe first step in drilling down to the root cause of this Quality Measure is to understand how the measure is calculated and the criteria for “Injurious Fall”. 

  • It is based on MDS Section J coded as one or more falls that result in major injury.
  • Major injury includes bone fractures, joint dislocations, closed head injuries with altered consciousness and subdural hematomas that occur as a direct result of the fall or are recognized after the fall that can be attributed to the fall


  • A resident will trigger this Measure on your MDS 3.0 Facility Quality Measure Report if one or more of their look-back scan assessments have the following question [J1900C] (Major Injury) coded as 1 (One fall) or 2 (Two or More falls).


  • All long stay nursing home residents with one or more look-back scan assessments.
  • A resident is excluded if one of the following is true for all of the look-back scan assessments:
  • the occurrence of falls was not assessed (J1900 = [-]), OR
  • the assessment indicates that a fall occurred (J180 0 = [1]) AND the number of falls with major injury was not assessed (J1900C = [-])
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It should be noted that dashes in these items is not appropriate and it is good clinical practice to conduct an assessment for any post fall related injuries post fall. 

This Measure is one of the look-back scan measures. If a long stay resident has had one or more falls with a major injury reported on one or more look-back scan assessments, it will trigger the measure.   For the Long Stay Measures the “look back scan” includes all assessment completed with ARDs up to 270 days from the ARD of the latest assessment in the quarter.  This means Falls with major injury will “trigger” for any “fall with major that occurred any time during a one-year period”.  The key to decreasing the score of this quality measure is in preventing falls, as this measure has such a lengthy look-back period.

What is the next step? Understanding the clinical Focus and Developing a Fall Prevention Process.  In the upcoming blog post, Part II of Quality Measure #8: One or more Falls with Major Injury, Harmony Healthcare International (HHI) will provide insight on how to develop a comprehensive fall prevention process. Topics will include Clinical Focus, Clinical Management Strategies, Root Cause Analysis and Establish a Falls Management Team.

Harmony Healthcare International (HHI) is available to provide onsite analysis and associated medical record reviews to help you improve your Quality Measure Scores.  Please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413. 
 Join us November 4th and 5th at Foxwoods Resort for the
5th Annual LTPAC Symposium
Featuring Guest Speaker Julia Fox Garrison
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Tags: Quality Measures, Injurious Fall

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