Someone with an intelligence quotient (IQ) of 130 may be considered above average for intelligence but still not understand the complexities of the MDS 3.0 Quality Measures (QMs). This series of articles on QMs will improve the QM IQs of healthcare professionals in long-term care, starting here with two long-stay fall measures among nursing home residents: Percent of Residents Experiencing One or More Falls with Major Injury and Prevalence of Falls. This article discusses the nuances of QM terminology to clarify the specifications that include the resident in the measure and how the methodology determines how long the resident will remain included.
Applying Key Terminology
The MDS 3.0 Quality Measures User’s Manual v16.0 defines key terminology used in the specifications of the QMs. The two measures reviewed here are described as long stay, meaning only residents with 101 or more cumulative days during the current episode of care in the facility are included. This statement alone requires further definitions from the Centers for Medicare & Medicaid (CMS, 2023) (boldface type added for emphasis):
- Cumulative Days in Facility (CDIF) is the “total number of days within an episode during which the resident was in the facility. It is the sum of the number of days within each stay included in an episode. If an episode consists of more than one stay separated by periods of time outside the facility (e.g., hospitalizations), and/or one or more stays with interruptions lasting 3 calendar days or less, only those days within the facility would count towards CDIF.”
- An episode is “a period of time spanning one or more stays. An episode begins with an admission [admission entry (A0310F = [01] and A1700 = [1])] and ends with either (a) a discharge, or (b) the end of the target period, whichever comes first.”
- Long-stay is defined as an “episode with CDIF greater than or equal to 101 days as of the end of the target period.”
Although the methodology for long-stay sample selection is applied automatically, it is helpful for facility teams to understand how it is calculated. The methodology first identifies when the current episode of care started (i.e., the resident’s most recent admission entry). Then it determines when the episode of care ended: either a discharge or death, or the end of the target period if the episode is ongoing. Next it counts how many cumulative days the resident had in the facility during this episode of care, excluding any days the resident was outside of the facility (e.g., during a hospitalization). If the CDIF was 100 or less, the resident is in the short-stay sample selection group; if 101 or more, he or she is included in the long-stay sample.
The two long-stay fall measures both use a look-back scan to determine which assessments should be included in the specifications. The long-stay look-back scan first identifies a target assessment within the target period and scans all qualifying reasons for assessment (RFAs) during the current episode of care and no more than 275 days before the assessment reference date (ARD) of the target assessment. This statement also requires defining new terminology (CMS, 2023):
- Look-back scan assessment selection methodology “scans all qualifying RFAs within the current episode that have target dates no more than 275 days prior to the target assessment.”
- Qualifying RFAs include the following:
- All OBRA Assessments “A0310A = [01, 02, 03, 04, 05, 06] or”
- PPS 5-Day “A0310B = [01] or”
- OBRA discharge return anticipated or return not anticipated “A0310F = [10, 11].”
- The selection logic for the look-back scan is to “include the target assessment and all qualifying earlier assessments in the scan. Include an earlier assessment in the scan, if it meets all of the following conditions: (a) it is contained within the resident’s episode, (b) it has a qualifying RFA, (c) its target date is on or before the target date for the target assessment, and (d) its target date is no more than 275 days prior to the target date of the target assessment. The target assessment and qualifying earlier assessments are scanned to determine whether certain events or conditions occurred during the look-back period. These events and conditions are specified in the definitions of measures that utilize the look-back scan.”
- The long-stay target period is 3 months.
- The target date is the “event date for an MDS record, defined as follows:
- For an entry record (A0310F = [01]), the target date is equal to the entry date (A1600).
- For a discharge record (A0310F = [10, 11]) or death-in-facility record (A0310F = [12]), the target date is equal to the discharge date (A2000).
- For all other records, the target date is equal to the assessment reference date (ARD, A2300).”
Using this terminology, teams can identify the long-stay look-back scan period for each resident. The team first pinpoints the current episode of care and the most recent qualifying RFA, considered the target assessment. Then they count back 275 days from the target date of the target assessment. All qualifying RFAs within this look-back are scanned for the measure condition.
Using Measure Specifications
Each QM has measure specifications that detail which residents are included in the numerator (the residents who have the measured condition) and in the denominator (the residents who could have the condition). Also calculated is whether any exclusions would prevent the resident from being included in the calculation and covariates that risk-adjust the calculation for some measures. The specifications for the two fall measures are detailed in this chart:
| Measure Name | Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) | Prevalence of Falls (Long Stay) |
| Measure Description | This measure reports the percent of long-stay residents who have experienced one or more falls with major injury reported in the target period or look-back period. | This measure reports the percentage of long-stay residents who have had a fall during their episode of care. |
| Numerator | Long-stay residents with one or more look-back scan assessments that indicate one or more falls that resulted in major injury (J1900C = [1, 2]). | Long-stay residents with one or more look-back [scan] assessments that indicate the occurrence of a fall (J1800 = [1]). |
| Denominator | All long-stay nursing home residents with one or more look-back scan assessments except those with exclusions. | All long-stay nursing home residents with one or more look-back scan assessments except those with exclusions. |
| Exclusions | Resident is excluded if the following is true for all look-back scan assessments: The number of falls with major injury was not coded (J1900C = [-]). | Resident is excluded if the following is true for all of the look-back scan assessments: The occurrence of falls was not assessed (J1800 = [-]). |
| Covariates | Not applicable | Not applicable |
To understand these measures, the team must apply all the terminology and definitions just reviewed. For example, consider the measure Percent of Residents Experiencing One or More Falls with Major Injury. The denominator includes all long-stay nursing home residents with one or more look-back scan assessments, except those who are excluded. The only exclusion for this measure is if falls with major injury (J1900C) was dashed on all assessments during the 275-day look-back scan from the target assessment. The numerator identifies the number of residents from the denominator selection that had a fall with a major injury coded (J1900C = 1 or 2).
Consider Mr. Connell, who has resided in the nursing home for two years. He has more than 101 CDIF, making him a long-stay resident for QMs. He experienced a fall with a major injury on July 31, 2023. The team completed a Significant Change in Status Assessment (SCSA) on Aug. 11, 2023, that captured the injury at J1900C. He had subsequent Quarterly assessments on Nov. 11, 2023, Feb. 2, 2024, and May 4, 2024. The interventions the team put in place have been successful, and Mr. Connell has not experienced any additional falls.
On May 15, the director of nursing services asks why Mr. Connell is still triggering for the fall with major injury QM because it has been more than 275 days since the fall occurred. Using the information from this article, the nurse assessment coordinator (NAC) can explain that the 275-day look-back starts from the most recent target assessment ARD on May 4, 2024, and it looks at the target date of the assessment that captured the fall, not the date the fall occurred. This results in a look-back period from May 4, 2024, through Aug. 3, 2023. Because the ARD that captured the fall with major injury was set on Aug. 11, 2023, it appropriately continues to trigger.
The NAC can also use this information to recognize that the next scheduled OBRA assessment, an Annual assessment with an ARD due by Aug. 4, 2024, will no longer capture the fall with major injury.
Conclusion
The methodology explained here means that when monitoring the two long-stay fall measures, the team can generally expect a fall or a fall with major injury to impact the QM for approximately a year. In the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, CMS explains that “falls are a leading cause of injury, morbidity, and mortality in older adults” and “a previous fall, especially a recent fall, recurrent falls, and falls with significant injury are the most important predictors of risk for future falls and injurious falls.” Although CMS does not state these are the reasons for the prolonged period of time a resident will trigger falls, we believe that keeping these recent falls on the QM reports for a year will help ensure the team uses this information for care planning and evaluations to prevent future falls.
Reference
Centers for Medicare & Medicaid Services. (2023). MDS 3.0 Quality Measures User’s Manual (V.16.0). https://www.cms.gov/files/document/mds-30-qm-users-manual-v160pdf.pdf
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