MDS Alert

Question: A couple of residents in my facilities have fallen in the past six months, some who had injuries that qualify as “major.” I noted the falls and injuries when they happened, but all of the falls are still triggering Certification and Survey Provider Enhanced Reporting (CASPER). Has the reporting information or timeline changed?

Maine Subscriber

Answer: Item J1700 (Fall History on Admission/Entry or Reentry) has a lookback history of 180 days, or six months, from the resident’s entry date. Item J1900 (Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent) has a lookback period that can vary due to other dates but is also quite extensive. Because falls trigger quality measures, a fall with or without major injuries stays on the CASPER report for at least 275 days, so a facility knows how it’s doing in relation to that quality measure.

Worried about that lengthy lookback period or how your facility will fare with those marks on the quality measures? Don’t be tempted to use dashes on assessments in order to lessen the impact of a fall on your facility.

“It should be noted that dashes in these items is not appropriate and it is good clinical practice to conduct an assessment for any post-fall-related injuries,” says Kris Mastrangelo, president and CEO of Harmony Healthcare International, in Topsfield, Massachusetts.

“The key to decreasing the score of this quality measure is in preventing falls, as this measure has such a lengthy look-back period,” Mastrangelo adds.