Federal definitions of nursing home falls and related injuries, and how they must be reported, are changing starting Wednesday. The changes threaten to compromise providers’ compliance and reimbursement efforts — even with no new risk to patients.

The latest version of the Minimum Data Set 3.0 Resident Assessment Instrument User’s Manual is effective with all entries made on Oct. 1 and beyond.

While changes range from the removal of an entire section to updates to therapy reporting requirements, it’s an expansion of the kinds of falls that need to be reported and concern about how non-major injuries stemming from falls can be interpreted that are raising the most concern.

Staff must now record falls that are the result of an “overwhelming external force,” such as being pushed by another resident or being knocked down by a med cart or other mobile device. Those used to be excluded from MDS forms, meaning they didn’t contribute to quality measure calculations.

That’s a big change moving forward, warned Alicia Cantinieri, managing director of Clinical Reimbursement & Regulatory Compliance for Zimmet Healthcare Services Group.

Adding another type of fall is likely to increase the prevalence of falls for a facility, while changing how surveyors can interpret major and non-major injuries also could lead more providers to increase how many falls they report.

“Our facilities may look worse just because of a change in definitions,” Cantinieri said. “We’ll find out.”

The expanded list

Before, the definition of major injuries associated with a fall included all bone fractures but only closed head injuries with altered consciousness or subdural hematoma.

Now, the list includes, but is not limited to:

• Traumatic bone fractures
• Joint dislocation/subluxations
• Internal organ injuries
• Amputations
• Spinal cord injuries
• Head injuries
• Crush injuries

Differentiating between major and minor fall injuries could be increasingly difficult with the Centers for Medicare & Medicaid Services adding ambiguity by adding “not limited to” both categories. Nursing home staff may assess the patients and determine a small scrape on the face is a minor injury, but a surveyor could see wording like that in a chart and find it indicative of a head injury — which must be classified as a major injury.

“Those key words, ‘but is not limited to’ are going to require some clinical judgment, and you want to make sure that you’re not missing coding anything that’s an injury because, again, it’ll show up on your iQies reports,” said Cantinieri. “The last thing that you want is the surveyor to say that you did not code an injury and then you have a whole host of F-tags waiting for you.”

Two-thirds of her audience predicted during a webinar last week that the new definitions would drive their quality measure performance down.

Intervention and documentation key

From there, QMs will inform Five-Star ratings, the SNF Quality Reporting Program and, starting in 2027, incentive payments through the SNF Value-Based Purchasing Program. Those carry high-risk penalties on top of citations a surveyor decides to give out any given day.

The new fall and injury wording “leaves it in the surveyor’s hands,” said Melanie Tribe-Scott, regional director of clinical reimbursement for AdviniaCare, which operates 13 facilities in three states.

“It leaves way too much room for interpretation,” she told McKnight’s Long-Term Care News Tuesday.

A disagreement between facility and inspector could lead to a citation for failure to assess, which could roll downhill into other tags for quality of care concerns or accidents and hazards.

“How do you protect yourself?” Tribe-Scott posed. “There’s got to be really good discussion by the interdisciplinary team. Facilities may even want to lean more into coding toward that major fall out of caution. It’s not a win-win for anyone.”

While questions are likely to arise on how fall-related injuries are captured, there’s little recourse or communication from CMS these days. Tribe-Scott suggested providers looking for more interpretation might be able to work with their state survey offices to better understand what inspectors will be looking for.

In the meantime, QAPI, care planning and person-centered care interventions will be critical to limit or reduce financial penalties. Documenting changes made for a patient with any fall, and each successive fall, will be critical as CMS ratchets up its attention on falls following a highly critical OIG report on the issue.

“We’re going to have falls. We all know we’re going to have falls,” Tribe-Scott said. “What matters is that the same type of fall does not recur with the same resident or population.”

Section R removal

Another area whose importance might be easy to overlook, said Cantineri, is a resident’s social determinants of health. Section R was supposed to be home to four new questions regarding living situation, food, utilities and transportation, but CMS removed it entirely.

“Just because it’s no longer on the MDS doesn’t mean that we can’t or shouldn’t ask these questions for discharge planning purposes. We have rehospitalization measures. We have resident quality of life,” she said.

“We want them to have a successful discharge home. We don’t want them ending up back in the hospital because some of these items are related to why people do end up back in the hospital,” she added. “They couldn’t get any food so they became malnourished or dehydrated. … or they don’t have a place to live so they end up being homeless, which brings them back sometimes into the healthcare system and ends up as a cycle for them.”

Cantinieri noted that the transportation question was saved and shifted into Section A of the MDS, though it’s completed only on a five-day PPS assessment with a stay of less than one year.