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Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)

CBE ID
0674
Endorsement Status
1.1 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Patient Safety Spring 2025
1.3 Measure Description

This measure reports the percentage of long-stay residents in a nursing home who have experienced one or more falls resulting in major injury (defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) reported in the look-back period no more than 275 days prior to the target assessment. The long stay nursing home population is defined as residents who have received 101 or more cumulative days of nursing home care by the end of the target assessment period. This measure is based on data obtained through the Minimum Data Set (MDS) 3.0 OBRA, PPS, and/or discharge assessments during the selected quarter(s).

        • 1.5 Measure Type
          1.7 Electronic Clinical Quality Measure (eCQM)
          1.8 Level Of Analysis
        • 1.14 Numerator

          The numerator is the number of long-stay residents with one or more look-back scan assessments that indicate one or more falls that resulted in major injury.

        • 1.15 Denominator

          The denominator consists of all long-stay nursing home residents with one or more look-back scan assessments except those who meet the exclusion criteria.

        • Exclusions

          A resident is excluded from the denominator of this quality measure if all look-back scan assessments indicate that data is missing from the data element assessing falls resulting in major injury during the look-back period preceding the target assessment.

        • 1.13a Data dictionary not attached
          No
        • Most Recent Endorsement Activity
          Endorsed Patient Safety Spring Cycle 2021
          Initial Endorsement
          Last Updated
        • Steward
          Centers for Medicare & Medicaid Services
          Steward Organization POC Email
          Steward Organization Copyright

          n/a

              • Risk adjustment approach
                Off
                Risk adjustment approach
                Off
                Conceptual model for risk adjustment
                Off
                Conceptual model for risk adjustment
                Off