3 categories can help everyone get on the same page.
The MDS 3.0 Section J1900 asks you to record the number of falls (0,1, 2 or more ) since admission or the prior assessment (OBRA, PPS, or Discharge), whichever is more recent, for each of the following categories.
A. No injury - no evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall.
B. Injury (except major) - skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain.
C. Major injury - bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma.
