MDS Alert
Don't Take A Fall For Omitting Falls In Section J
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Question: If we walk into a room and find a resident on the floor, and the person is too cognitively impaired to tell us how she got there, do we count that as a fall in coding Section J4 on the MDS? Source: Andrea Platt, RN
Answer: The RAI manual addresses this situation (p. 3-146) and states that unless there is evidence suggesting otherwise, the most logical conclusion is that the person fell. So if you can't determine how the person ended up on the floor, code that as a fall in Section J.
In all cases, you will want to assess how a resident ended up on the floor and whether she is injured as the result of a fall.
The RAI manual states: "When a resident is found on the floor, the [nursing] facility is obligated to investigate and try to determine how he/she got there and to put into place an intervention to prevent this from happening again."
Thomas Healthcare Consulting
Indianapolis
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