OIG Report Reveals Underreporting of Major Injury Falls in Medicare Nursing Homes

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a report revealing significant underreporting of major injury falls in nursing homes. The analysis covered data from July 1, 2022, to June 30, 2023, linking hospital Medicare claims with nursing homes' Minimum Data Set (MDS) assessments. It identified that 42,864 Medicare-enrolled residents experienced a fall causing major injury and hospitalization, with 1,911 deaths occurring during hospitalization.

However, nursing homes failed to report 43% of these incidents in their MDS assessments as required by Centers for Medicare & Medicaid Services (CMS) regulations. Larger nursing homes with over 160 beds had an even higher non-reporting rate of 45%. Geographically, non-reporting was most prevalent in Washington, D.C., California, and Nevada, while South Dakota, Vermont, and North Dakota exhibited the lowest rates.

The report also found systemic disparities in reporting, with younger, male, and short-stay residents' falls less likely to be documented than those of long-stay residents. This underreporting impacts the reliability of nursing home quality metrics, particularly those published on CMS' Care Compare website, where nursing homes reporting the lowest fall rates were often the same entities failing to report major falls. The OIG highlighted the difficulty in accurately determining fall rates due to differences in the data sources and types of falls reported on Care Compare.

To address these issues, OIG recommended that CMS enhance compliance efforts through collaboration with state agencies, improved education and training on fall reporting, intensified review of MDS assessments during nursing home surveys, and advanced data validation techniques including medical record audits as part of existing value-based purchasing programs. Furthermore, OIG suggested extending these measures to other quality indicators based on MDS data. CMS has agreed with these recommendations and is working with a Technical Expert Panel to revise the falls with major injury quality measure. The updated measure under development will incorporate claims and encounter data alongside MDS to improve accuracy and reduce the effect of under-reporting.