MDS Alert

Published on Mon Feb 20, 2017 PDF

Question: I’m a Physical Therapy Assistant (PTA) at a nursing facility and am in charge of tracking and running a monthly meeting on falls in our facility. I have been looking at the CASPER report to try to find how our facility rates in falls with the state and the nation. What is the exact definition of a fall that facilities are to use to determine what constitutes as a fall? Is there a national average of falls per month that we can use to compare to? 

Also, on the CASPER report, do the falls per month averages stay constant or do they change each reporting period based on how many falls happened in the state/nationally? On the comparison group national percentile, what is the first number that is flagged (our facility is at 82 and is flagged, and I am curious how low we need to get to not be flagged)?

Answer: The RAI Manual (page 3-J-27) defines a “fall” as:

“Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall, no matter whether it occurred at home, while out in the community, in an acute hospital or a nursing home. Falls are not a result of an overwhelming external force (e.g., a resident pushes another resident).” 

“An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person — this is still considered a fall.”

Statistics change with every MDS that facilities submit, says Marilyn Mines, Rn, BC, RaC-Ct, MDS Alert Consulting Editor and Senior Manager at Marcum LLP in Deerfield, Ill. Therefore, the “average” is a moving target.

“The CASPER report and statistical information to be utilized is on the Facility QM/QI report,” which you should review and analyze at least quarterly, Mines instructs. “Of course, an investigation of each fall should occur at the time of the incident.”

Surveyors use the QM/QI report to identify the resident sample and areas of potential concern. The survey team must investigate any sentinel event, any QM/QI that is flagged at the 90th percentile, as well as any unflagged QM/QI in which the facility is at the 75th percentile.

“Again, because of the national and state comparisons to determine the percentile, it is not possible to say what number or how low you must get to make the 82 percent lower,” Mines explains. “The fewer falls identified on MDS assessments, however, the lower the percentile. This QM/QI is determined by the number of residents who had a fall within the past 30 days, divided by all residents with a target assessment.”