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 TypeElectronic Clinical Quality Measure (eCQM)Level Of AnalysisCare SettingNumerator
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.
DenominatorThe denominator consists of all long-stay nursing home residents with one or more look-back scan assessments except those who meet the exclusion criteria.
ExclusionsA 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.
Testing Data Sources
- Measure StructureNon Condition SpecificTarget PopulationMeasure Selection AttributesNational Quality Strategy PrioritiesPatient Safety
- Risk Adjustment
- Current or planned use(s)Current Use(s)
- Most Recent Endorsement ActivityEndorsed Patient Safety Spring Cycle 2021Initial EndorsementNext Planned Maintenance ReviewPatient Safety Spring 2025Endorsement StatusLast Updated
- Steward Organization EmailSteward Organization Copyright
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