Assessment of nursing home reporting of major injury falls for quality measurement on nursing home compare

Abstract

Objective To assess the accuracy of nursing home self‐report of major injury falls on the Minimum Data Set (MDS). Data Sources MDS assessments and Medicare claims, 2011‐2015. Study Design/Methods We linked inpatient claims for major injury falls with MDS assessments. The proportion of claims‐identified falls reported for each fall‐related MDS item was calculated. Using multilevel modeling, we assessed patient and nursing home characteristics that may be predictive of poor reporting. We created a claims‐based major injury fall rate for each nursing home and estimated its correlation with Nursing Home Compare (NHC) measures. Principal Findings We identified 150,828 major injury falls in claims that occurred during nursing home residency. For the MDS item used by NHC, only 57.5 percent were reported. Reporting was higher for long‐stay (62.9 percent) than short‐stay (47.2 percent), and for white (59.0 percent) than nonwhite residents (46.4 percent). Adjusting for facility‐level race differences, reporting was lower for nonwhite people than white people; holding constant patient race, having larger proportions of nonwhite people in a nursing home was associated with lower reporting. The correlation between fall rates based on claims vs the MDS was 0.22. Conclusions The nursing home‐reported data used for the NHC falls measure may be highly inaccurate.

Association Between Cognitive Status and Falls With and Without Injury During a Skilled Nursing Facility Short Stay

“…A study comparing MDS assessments and Medicare hospital claims between 2011 and 2015 found that falls with major injury were less likely to be documented in the MDS for nonwhite residents than white residents when compared to hospital claims for major injury falls. 31 Our findings have potential implications for incentivizing nursing homes to provide high-quality care. As part of the 2014 Improving Medicare Post-Acute Care Transformation Act, SNFs, inpatient rehabilitation facilities, home health agencies, and long-term care hospitals are required to report common quality measures.…”

“…First, there is evidence that nursing homes under-report the number of falls in the MDS. 31 Second, we were not able to account for facility-level differences in fall incident reporting practice across SNFs (eg, not reporting near-miss falls, nursing staff assisting residents to the floor but without injuries). 31,35 Third, we excluded residents who died during their SNF stay.…”

“…31 Second, we were not able to account for facility-level differences in fall incident reporting practice across SNFs (eg, not reporting near-miss falls, nursing staff assisting residents to the floor but without injuries). 31,35 Third, we excluded residents who died during their SNF stay. Consequently, residents who may have been at the greatest risk to experience a fall were removed from the analysis.…”

Inside the Black Box of Improving on Nursing Home Quality Measures

“…Yet, skepticism about the validity of the self-reported pain QMs seemed consistent with the creative strategies many providers employed to improve their pain scores, some of which could be considered gaming. A recent study using Medicare claims found that a substantial percentage of falls resulting in serious injury (42.5%) were not reported on the MDS (Sanghavi et al, 2020). Given that CMS has changed or replaced several QMs over time, it is likely that CMS too has concerns about some of the QMs.…”

Appropriate Nurse Staffing Levels for U.S. Nursing Homes

“…59 For example, only 57.5% of major injury falls were reported on MDS data compared with actual claims data. 60 Nursing homes have an incentive to under-report indicators of poor quality to receive higher quality ratings and to avoid scrutiny from state surveyors, consumers, advocates, journalists, and managed care payers with whom nursing homes are contracted to provide short-stay care.…”