Accountability, Prevention, And The True Cost Of Missed Falls

A troubling statistic sits at the center of today’s conversation: 43% of nursing home falls with major injury and hospitalization went unreported through the MDS. We dig into what that means for resident safety, survey outcomes, quality measures, and reimbursement—and how to fix it fast. Joining me is Janeen Earwood, a physical therapist with four decades of experience in long‑term care, rehab leadership, and analytics. Together, we connect the dots between OIG’s findings, CMS’s plans to validate MDS entries with Medicare and Medicaid claims, and the operational steps facilities can take to prevent harm while protecting data integrity.

Transcript

SPEAKER_01 0:09

Hello, I will be your host. My name is Deanna Five. I am a registered nurse and healthcare analyst. Let's get started.

SPEAKER_00 0:20

The views or opinions expressed in this podcast are for informational purposes only, not intended as legal or professional advice, and may not represent those of Verity Consulting. Although we make strong efforts to make sure our information is accurate at the time the podcast episode was recorded, Verity Consulting cannot guarantee that all information in this podcast is always correct, complete, or up to date. All information in this podcast is subject to change without notice.

Guest Introduction & Credentials

SPEAKER_01 0:51

Today, this episode will be focusing on falls with major injury in long-term care facilities. And today will be a day where I have a special guest joining me. And I worked with this young lady for many years in doing healthcare quality compliance reviews. And we worked as well doing corporate integrity agreements for the Office of Inspector General. So I'm very happy today to introduce Janine Irwood.

SPEAKER_02 1:26

Hi, Dee. Thank you so much for having me today. As Dean mentioned, she and I had the pleasure of working together for a number of years as monitors and my background, I'm a physical therapist by background. I have 40 years this year as of experience as a physical therapist. My work has primarily been in long-term care and inpatient rehab. Starting in about 2004, I began working in long-term care. Both as vice president of rehab and most recently as vice president of strategy and analytics for a large healthcare company that is a multi-state presence. Really excited to talk today about falls and fall prevention.

SPEAKER_01 2:11

Now, today we're going to talk about an Office of Inspector General report that came out September of 2025 titled Nursing Homes Failed to Report 43% of falls with major injury and hospitalization among their Medicare enrolled residents. So in that OIG report, there's a great deal of detail about the findings when there was a review of falls with major injury. Now, it talks about MDS accuracy, of course. It talks about Medicare, Medicaid claims data. So what I'm going to do is ask Janine to talk a little bit about this in a little more detail from her experience.

CMS Response And Data Validation

SPEAKER_02 2:55

So, you know, OIG has been very transparent about their interest in quality of care issues. And that has only increased over the last several years as they monitor what's going on with long-term care and continue to give recommendations to CMS. And when they did this look at claims-based data and compared it to what was being reported in MDSs and found such a disparity, it certainly raised concern on the part of OIG and resulted in these recommendations that are in the report that you just referenced to CMS. And then CMS, in their response, certainly agreed that this was of significant concern and noted that they are now using claims data both from Medicare and Medicaid across the continuum of care to validate that the falls with major injury data in the MDS, MDSs that are submitted is accurate. And I think that it will be a certainly guidance to surveyors, if not a more aggressive approach in the future with regard to any disparities that they see in the in the comparison of these two data sources.

Leading Risk Factors For Falls

SPEAKER_01 4:19

So at the facility level, are we doing audits? Are we looking at how we are coding? Obviously, that's the that's important. But before that, what is our fall prevention program? What's our systems level review of compliance to prevent falls from the get-go? So I want you to talk a little bit more about fall prevention and some best practices that you've seen.

Root Cause Over Labels

Individualized Interventions That Work

SPEAKER_02 4:45

Well, and and I think that when you think about the leading factors that result in falls with major injury, it's the same leading factors that lead into falls in the first place. And unfortunately, in some cases, you know, a fall results in a fracture or significant laceration, et cetera. You know, residents' cognitive status, of course, comes to mind as a first step, really safety awareness here. If a resident may have, you know, dementia that has resulted in memory loss, but safety awareness may have been retained in the short run. And on the other hand, however, there may be residents who do well on a BIMS but have really poor safety awareness. And then history of falls, of course. So the more frequently you fall, you know, just statistically speaking, the more likely you are to have an injury. And so when we have a resident with a history of falls, the real issue here is how effective are our fall interventions. Are those interventions individualized for the resident? Are we doing a root cause analysis at the time of the fall to really drill down to see why did the resident fall? They didn't fall because they have dementia or because they have Parkinson's disease. They fell because they were trying to do something. And so, really, you know, interviewing the resident, understanding what their motivation was for perhaps trying to get up out of the wheelchair or get out of bed really gives us insight into what kind of intervention to put in place to prevent future falls.

SPEAKER_01 6:34

So what I hear you saying is putting that fall prevention program in place, a comprehensive fall prevention program. So tell me a little bit more about some of the elements of that program.

Building A Replicable Falls Program

Pre‑Admission Risk And Early Actions

SPEAKER_02 6:46

Absolutely. And so having a falls program within the organization that is structured and replicable has to be sort of a foundation for a successful facility. Starting really pre-admission, you know, is there a fall risk assessment that is completed by the interdisciplinary team prior to the resident ever arriving at the facility, recognizing what's really happening with them, what are their diagnoses, why are they in the hospital, have they already had a fall? And then implementing interventions prior to the resident ever coming to the building really gets you set off at the right on the right foot. And then following that with any significant changes as they occur and continuing to use standardized tools to identify fall risk. But while standardized tools are great, they don't make up for truly knowing our residents and truly knowing what the motivating factors are for that individual resident as we get to know them in the facility. And then continuing on with our quarterly assessments or any time that there is a significant change.

SPEAKER_01 8:05

So what you're saying is you've conducted a risk assessment of a resident, you've put a plan in place that you believe is going to help prevent falls, and you reassess and reevaluate. But let's say, despite all your efforts, the resident continues to have fall experiences. What do you do then? Take me down that path.

Reassessments And Knowing Residents

When Falls Persist: The Playbook

Post‑Fall Huddles And Tools

Streamlining Care Plans

SPEAKER_02 8:28

And and so if I if I kind of walk through a process, I would say that the root cause analysis that's done by the team at the time of the fall is the key step in terms of obviously if no one, if a resident hasn't had any falls, then you're doing a good job, right? But it if we have a fall, to pull together an interdisciplinary team that includes the CNA that's caring for the resident, the nurse that is responsible for the care of the resident, any of the nurse leadership that is available, the director of therapy to take a look at the fall circumstance and talk to the resident at the time of the fall. Often these are called post-fall huddles. And using a standardized tool to always capture the same information during that little gaggle up to see what you know what really happened during this fall is a key. And then identifying an immediate intervention that will address whatever the circumstance was, and including that on the care plan, of course, very, very important. Then next step being whenever the interdisciplinary team has their next meeting, whether that's at the end of the day or the beginning of the next day, that a more in-depth root cause analysis is reviewed and identifying what were the factors that were involved in this fall. During that process, reviewing the entire care plan related to falls. So let's say that this is a resident that's been with us for three years. And during that three years, they've had multiple falls. Not only looking at this fall, but looking for commonalities across the most recent falls that the person has had, often will identify additional information that one fall might not. And then upgate updating the care plan again truly with an intro an individualized intervention. So for example, if a resident was attempting to get out of bed into the wheelchair, and they tell you that they were, you know, they wanted to get up and their feet slid out from under them, we wouldn't put in an intervention that related to bathroom safety, right? We we have to drill down to what really happened and identify an intervention that relates to that specific issue. Often we also see that in care plans if a resident has been with us for a long time and if they have fallen multiple times. Our fall prevention care plan might be pages long. And so if that's the case and you're the direct care provider for that resident, it's difficult to sift through all of the interventions that are listed on the care plan to identify truly what you should be doing in the care of the resident to keep them safe. And so winnowing your care plan to interventions that are truly individualized and proven to be effective, and don't say, you know, sort of generic items that we do for all of our residents really results in a much more effective care plan.

SPEAKER_01 11:50

So would you say getting this information to direct care staff, the team, so they know what it is we need to do?

SPEAKER_02 11:58

Absolutely. And and you know, when when we are together as an IDT and we are discussing and we've come up with a great new intervention and we're super excited about it, and we put it in the care plan, if we then all walk away and nothing else is done, how does the direct care provider know what it is that they're supposed to do that's new and different? And so a method for communication real time that might be a you know post-morning clinical meeting, you know, gaggle up with the direct care staff on the unit where the fall occurred, in which we talk about Mrs. Jones had a fall, this was the circumstance, and here's the intervention we would like to put in place. And then that that communication goes shift to shift on the go forward so that it's communicated directly, not just via the care plan, but also in a in a you know face-to-face way.

Therapy Screens And Mobility

SPEAKER_01 12:56

So, you know, you talked a little bit about huddles or uh manners by which the staff come together and talk about here's our plan, here's how we're going to keep this resident from falling, certainly from having a major fall. And we know that it's important for the interdisciplinary team to talk, keep each other updated, any changes that is occurring with the resident, any early changes that could lead to their falls, certainly a major fall. So talk a little bit about that. So we want to we want to avoid falls, we do not want any further incidents. So talk a little bit about that.

Gap Analysis To Reduce Falls

SPEAKER_02 13:37

And and to your point there, you know, then three or four days later, most facilities have something that they would call resident review, incident review, something like that, and in which once a week they review residents that have had major changes. And so another recommendation then would be for any resident that's fallen in the last seven days since your last resident review meeting to go back and look at the intervention that was put in place after the most recent fall, and then discuss whether that intervention has been effective in the last few days and pulling in the direct care staff who directly treat care for the resident, the CNAs, and saying, What do you think? Is this working? Was this intervention effective? Should we try something else? And then, of course, documenting that discussion, right, would be an important piece. Of course, being a therapist, I have to throw in the therapy screen. So most facilities that I have worked with over the years that have really effective fall prevention programs. Their therapy team is highly engaged in all things fall prevention, both with regard to actual therapy treatment, resident equipment, positioning, et cetera. And that therapy screening process after a fall will take a look at whether there has been a change in independence with regard to mobility. And if so, then therapy, you know, seeks evaluate and treat orders and initiates treatment to try to address any change in mobility and move that person back up to their level of prior functioning. You know, if I if I would think about facilities that I have worked with over the years that have really struggled with high fall rates, an approach we used as monitors very frequently was something of a gap analysis in which we looked at the falls program of the facility. And typically every facility across the country would have a fall prevention program. And then we would say, okay, you know, there's 12 steps in this program, and then assess whether the individual facility was effectively using all of those steps. And if a gap was identified, then we would work with the facility to identify what the roadblocks are to implementing that missed step. And often we would see significant improvements involved.

Deep Dives On Repeat Fallers

SPEAKER_01 16:12

In my experience as a monitor, I have worked with organizations to conduct gap analysis exercises to look at resident falls. And looking at that is what you're doing is you're getting the policy and procedure out. That once you once you review that, are there any gaps in what we were supposed to do? What did we not do? That's identifying the gap. And from there you go. I had some great experiences doing that. And one thing I want to emphasize here is it's really important to get key stakeholders involved. Make sure that folks who know the residents and know what's going on with the residents on a day-to-day basis, all shifts, weekends, et cetera, that they are brought to the table to provide feedback on what their view is as to contributing factors for falls. So it's real important, key stakeholders. Well, you nicely outlined some of the steps that go into root cause analysis, gap analysis. What else are you doing? Can you tell us a little bit more?

Med Review And Care Plan Fidelity

SPEAKER_02 17:11

Some work that I'm doing right now in my company relates to really residents who have the unfortunate circumstance of having repeated falls over and over again. And so we're doing some work with regard to more of a deep dive analysis across falls in the same resident, looking at things like, you know, what are the diagnoses that this resident has? What are if we look at the circumstance or the events occurred in the in the last, you know, let's say five falls, what are the commonalities? Time of day, location, you know, what is the resident saying? And then looking at the BIMs. Is the resident able to remember these safety instructions that we give them? If not, what else do we need to be doing? Looking at the most recent therapy documentation and identifying the mobility status at the time of discharge, comparing that to the mobility status that we're seeing now, and asking for therapy referrals, if indeed we're seeing a decline. Reviewing care plan interventions to ensure that the interventions that are listed in the care plan are current, are effective, and are in place. So if the facility has a customer service rounding process, you know, we call it concierge rounds. Sometimes they're called guardian angel rounds. Is that concierge or guardian angel taking a look at safety every time they go into that resident room to see if the plant care planned interventions are in place? Next up, what medications is the resident on? Are they on a number of medications that are known to have potential side effects of dizziness, faintness, you know, uh vertigo, et cetera? Is there an opportunity for gradual dose reductions on psychoactive meds, which often result in issues with falls? Looking at provider notes and provider orders, not just of the direct care, sorry, the medical director or physician caring for the resident, but any consultations, perhaps psych notes, et cetera. And then based on that, what are we seeing as the commonalities across all of these pieces of data that may give us insight into what else might we be able to do to prevent future falls with the same resident?

Time Investment And Resident Safety

Auditing MDS For Accuracy

SPEAKER_01 19:53

And this is certainly a time commitment. I mean, you're you're bringing folks together to start talking about what we can do to prevent falls, certainly major falls. It is a commitment, but it's well worth it because we're going to protect the resident. So we've talked about fall, fall prevention, uh avoiding major injuries. I want to go back again to the OIG, the CMS initiative to really examine more closely MDS accuracy and uh and Medicaid Medicare claims. So come back to that and talk a little bit more about that.

Quality Measures And Reimbursement

SPEAKER_02 20:33

Certainly. And and you know, when you take a look at OIG guidance for long-term care in terms of internal audit and the kinds of things that we should be monitoring, one of the key elements is MBS accuracy, whether that is either for Medicare residents, but also truly for your Medicaid residents and your managed care residents as well. And so developing a standardized tool that you can use to do that auditing and then reporting that, those results to your compliance committee, as well as if there are errors in your MDSs, that you are modifying the MDSs to correct the errors, which may result in decreased reimbursement or may result in increased reimbursement based upon the timing of your audits. But a newer factor that OIG has really been focused on recently has been accuracy of MDS data as it relates to those factors that are included in quality measures and any quality reporting that results in changes to reimbursement. And so things like accuracy of if a resident has had a major injury due to a fall, is that coded correctly on an MDS is a perfect example of something that might. Be on your audit tool to ensure that you are aware of the accuracy of your MDSs in an individual facility or across a company.

SPEAKER_01 22:08

So, Janine, we know that the oversight, the review that will be conducted will have some far-reaching implications. You want to talk a little bit about that?

SPEAKER_02 22:19

Absolutely. Absolutely. And you know, one other thought related to OIG's focus and ultimately CMS's focus relates to special focus facilities. And so, you know, the fall prevalence of falls being a new component of determination of which facilities will become special focus facilities across the country, it just adds even more emphasis on the importance of fall prevention and the importance of really understanding what the gaps are in your falls programs and how to better prevent falls.

SPEAKER_01 22:53

Well, I think we have really conducted a pretty comprehensive review of the discussion related to falls with major injury, the implications indicated by the OIG and the CMS and where things are going to go. It's been great having you come in and share with me some of this information, and I hope to have you come back. There are a few more topics that I know you'll be able to help us develop and have some good discussion. Thank you again, Janine.

SPEAKER_02 23:25

I would love it, Dee.

SPEAKER_01 23:28

Thank you for listening. Your time is appreciated. We hope you enjoyed this episode of Vital Compliance Insights and found this to be informative. Please feel free to reach out to Verity Consulting at VerityTeam.com if you'd like further assistance with your healthcare compliance needs. Stay tuned for the next episode.