Measure Description Numerator

Improving the Quality Measures: Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)

Measure Description This measure reports the percent of long-stay residents who have experienced one or more falls with major injury reported in the target period or lookback period.

1

Numerator Long-stay residents with one or more look-back scan assessments that indicate one or more falls that resulted in major injury (J1900C = [1, 2]).

1,2

2

Denominator All long-stay residents with a one or more look-back scan assessments except those with exclusions.

3

Exclusions Resident is excluded if one of the following is true for all of the look-back scan assessments: 1. The occurrence of falls was not assessed (J1800 = [-]), or 2. The assessment indicates that a fall occurred (J1800 = [1]) and the number of falls with major injury was not assessed (J1900C = [-]). -

4

Exclusions 2. The assessment indicates that a fall occurred (J1800 = [1])

and the number of falls with major injury was not assessed (J1900C = [-])

5

How to Make Improvements 1. Refer to RAI Manual Appendix C: Care Area Assessments/Falls and for each resident who triggers review: • History of falling • Physical performance limitations: balance, gait, strength, muscle endurance • Medication history

6

How to Make Improvements • • • •

Internal risk factors Laboratory tests Environmental factors Input from resident and/or family/representative

7

How to Make Improvements 2. Analyze your findings for each resident and document: • A description of the problem; • The causes and contributing factors • The risk factors related to the care area 3. Develop and implement an individualized plan of care based on the analysis

8

The Change Package: Strategies of High-Performing Nursing Homes Provide exceptional compassionate clinical care that treats the whole person by striving to prevent problems: Reduce the likelihood of falls

Download the Change Package: https://www.lsqin.org/wpcontent/uploads/2015/03/NH-ChangePackage032615-Final-508.pdf

9

Contact the Lake Superior Quality Innovation Network Michigan: MPRO Kathleen Lavich 248-465-7399 [email protected]

Minnesota: Stratis Health Kristi Wergin 952-853-8561

[email protected]

Wisconsin: MetaStar Liz Dominguez 608-441-8266 [email protected]

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Resources •

•

MDS 3.0 RAI Manual: https://www.cms.gov/Medicare/Quality-InitiativesPatient-AssessmentInstruments/NursingHomeQualityInits/MDS30RAI Manual.html MDS 3.0 QM User’s Manual: https://www.cms.gov/Medicare/Quality-InitiativesPatient-AssessmentInstruments/NursingHomeQualityInits/NHQIQualit yMeasures.html

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This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-C2-16-23 012716