Nursing Homes Failed To Report 43 Percent of Falls With Major Injury and Hospitalization Among Their Medicare-Enrolled Residents

Report Materials

• Full Report(PDF, 1.7 MB)
• Report Highlights(PDF, 362.1 KB)
• Companion Data Snapshot
• Adverse Events Featured Topic

Why OIG Did This Review

• CMS's Care Compare website is intended to provide consumers with reliable information about quality of care to inform their choices. For nursing homes, the quality measures displayed on Care Compare include rates of resident falls with major injury.
• To calculate the quality measures for falls with major injury, CMS uses data that nursing homes report from Minimum Data Set (MDS) resident assessments.
• Providers may have a disincentive to report events, such as falls, that could result in lower scores on quality measures. Previous analyses by OIG and others have identified under-reporting by providers.

What OIG Found

Nursing homes failed to report 43 percent of falls with major injury and hospitalization among Medicare-enrolled residents, as required, in resident assessments.

• For-profit and chain nursing homes as well as larger nursing homes failed to report falls most often.
• Fall reporting varied widely by State and was worse among nonrural nursing homes.
• Nursing homes failed to report falls more often for younger residents, male residents, short-stay residents, and residents with only Medicare coverage.

Nursing homes' failure to report falls on MDS assessments leads to inaccurate fall rates on Care Compare.

• Nursing homes with the lowest fall rates on Care Compare were the least likely to report the falls we examined. This suggests that low fall rates for nursing homes on Care Compare are likely driven by nursing homes' failure to report falls, rather than an actual low incidence of falls.
• As a result, Care Compare does not provide the public with accurate information about how often nursing home residents fell.

OIG released a companion data snapshot describing the falls we reviewed, the characteristics of the residents who fell, and the characteristics of the nursing homes where the falls occurred.

What OIG Recommends

1. CMS should take steps to ensure the completeness and accuracy of the nursing home-reported MDS data used to calculate the quality measures for falls with major injury.
2. CMS should explore whether approaches to improve the quality measures related to falls could similarly be used to improve the accuracy of other nursing home quality measures.

CMS concurred with both recommendations.