If a patient experiences a fall with no immediate injuries but a day or two later complains of pain and is sent to ER and admitted (fracture), how should this be coded on the Discharge MDS?

Question: A patient experiences a fall late in the evening with no immediate injuries identified. A day or two later, the patient complains of pain upon rising and is sent to the ER. The patient is admitted to the hospital and diagnosed with a fracture. The fracture was diagnosed after the patient was discharged from the facility. How should this fall be coded on the Discharge Assessment?

Answer: The ARD for the Discharge Assessment is the day that the patient left the facility. in the case scenario described above, Section J 1800 should be coded to reflect the fall.

When addressing the injury in Section J 1900, the RAI User's Manual defines a fall related injury as any injury that occurred as a result of, or was recognized within a short period of time (a hours to a few days) that can be attributed to the fall.

In this case, the fall occurred on or prior to the ARD (during the assessment look back period) although the fracture may not have been recognized until after the patient was discharged from the facility, the fall with major injury should be coded on the MDS.