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Disclaimer

In the Downloads section, the ‘Prior Submission’ file reflects the most recent measure submission to the former CBE. This file is provided for transparency. For any questions or clarification, please contact the designated measure steward.

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

CBE ID
0674
Endorsement Status
1.0 New or Maintenance
1.1 Measure Structure
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Spring 2027
1.6 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).

    Measure Specs
      General Information
      1.7 Measure Type
      1.3 Electronic Clinical Quality Measure (eCQM)
      No
      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.

      1.13 Data Dictionary
      Not attached. I attest that all information will be provided where codes and/or value sets are needed (1.14a - 1.15c).
      Most Recent Endorsement Activity
      Endorsed Patient Safety Spring Cycle 2021
      Initial Endorsement
      Last Updated
      Steward Organization
      Centers for Medicare & Medicaid Services
      Steward POC email
      Steward Organization Copyright

      n/a

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