Falls among older adults, including nursing home residents, are common, costly, and often preventable. According to the Agency for Healthcare Research and Quality (AHRQ), approximately half of nursing home residents experience a fall in any given year, resulting in serious injuries and decreased quality of life for residents.
A Centers for Disease Control and Prevention study estimated that in 2015 Medicare and Medicaid programs spent $28.9 billion and $8.7 billion, respectively, on health care related to older adults’ falls. While not all falls can be prevented, research has shown that nursing homes’ fall rates can be reduced with the implementation of comprehensive fall prevention programs.
Minimum Data Set (MDS) Resident Assessments
MDS resident assessments are one tool for monitoring nursing home quality of care. The Centers for Medicare & Medicaid Services (CMS) requires Medicare- and/or Medicaid-certified nursing homes to conduct standardized resident assessments using the MDS instrument. These assessments collect information about each resident’s health, physical functioning, mental status, and general well-being, including whether the resident experienced falls. The nursing home staff conducting the assessment, not the resident, complete the assessment. MDS assessments must be completed upon nursing home entry, every 90 days thereafter (quarterly), upon significant change in resident status, and at the end of the nursing home stay (discharge or death). When a resident is admitted to the hospital, the nursing home must complete a discharge assessment within 14 calendar days after the nursing home discharge date and transmit it to CMS within 14 calendar days after completion.
CMS calculates two nursing home quality measures from the MDS that reflect the percentage of residents who experienced a fall with major injury for each nursing home:
- Long-stay measure: rate of falls with major injury among long-stay residents.
- Medicare Part A SNF-stay measure: rate of falls with major injury among residents during Medicare Part A SNF stays (which are generally shorter).
These measures are calculated from MDS items that record whether the resident experienced a fall during the episode of care and, if so, the severity of any injuries resulting from that fall. These items are part of the discharge assessment that is required upon a nursing home resident’s hospital admission. According to CMS, when a nursing home does not know about a fall or a fall’s severity at the time of the nursing home discharge, the nursing home should update the discharge assessment when it becomes aware of the fall or aware that the severity originally reported was not accurate.
OIG reviewed nursing homes’ reporting of falls with major injury that resulted in Medicare-paid hospitalization among residents in MDS assessments completed in the 1-year period between July 1, 2022, and June 30, 2023. The study focused on the subset of nursing home resident falls resulting in a hospital admission because (1) nursing homes must submit a discharge assessment and report any falls when a resident is admitted to the hospital and (2) OIG can independently verify hospitalizations in the Medicare claims
On September 18, 2025, the U.S. Department of Health and Human Services Office of Inspector General announced the results of its review of nursing homes reporting of resident falls:
Nursing homes failed to report 43 percent of falls with major injury and hospitalization among Medicare-enrolled residents, as required, in resident assessments.
As a result, Care Compare does not provide the public with accurate information about how often nursing home residents fell.
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 OIG 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.
“During our 1-year review period, nursing homes failed to report 18,369 (43 percent) of the 42,236 falls resulting in a major injury and hospitalization that we identified among Medicare-enrolled nursing home residents, as required in
MDS assessments. This high rate of nonreporting indicates nursing homes’ poor overall compliance with CMS’s fall
reporting requirements.”
If you or a loved one may have been injured (or worse) as a result of malpractice in a nursing home in the United States due to nursing home fall, nursing home staff shortage, nursing home understaffing, nursing home pressure ulcer (nursing home bedsore), a nursing home infection, nursing home aspiration, nursing home neglect, nursing home negligence, nursing home abuse, or the nursing home failing to properly care for a vulnerable adult, you should promptly find a nursing home malpractice lawyer who may investigate your nursing home malpractice claim for you and represent you or your loved one in a nursing home malpractice case, if appropriate.
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