The Oct. 1, 2025, update to the definitions of “fall” and “major injury” in the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual) has left many nurse assessment coordinators (NACs) with questions about what this change means for coding decisions and Quality Measures (QMs). At the AAPACN 2026 Conference, Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, senior curriculum development specialist for AAPACN, will shed some light on this topic during her session “From Sand to Solid Ground: Strengthening Your Understanding of Falls and Major Injury.”
To further complicate the update, two sources use the major injury definition but in very different ways: the Minimum Data Set (MDS) 3.0 Percent of Residents Experiencing One or More Falls with Major Injury and the Skilled Nursing Facility Quality Reporting Program (SNF QRP) measure Application of Percent of Residents Experiencing One or More Falls with Major Injury. This article dives into how the new definitions impact QMs, explains how the two measures differ, and highlights strategies to improve quality outcomes.
New Definitions
The changes to the definitions of “fall” and “major injury” for MDS coding alter what qualifies as a fall and when the criteria for a major injury related to the fall is met. Although some of the changes add clarification, others may cause confusion. In October 2025, the RAI User’s Manual provided these updated definitions related to falls:
| FALL Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat) or the result of an overwhelming external force (e.g., a resident pushes another resident). An intercepted fall occurs when the resident would have fallen if they had not caught themself or had not been intercepted by another person—this is still considered a fall. INJURY (EXCEPT MAJOR) Includes, but is not limited to, skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain. MAJOR INJURY Includes, but is not limited to, traumatic bone fractures, joint dislocations/subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries, and crush injuries. (CMS, 2025) |
To summarize the changes, the definition of a fall was expanded to include a fall caused by “an overwhelming external force,” which was previously excluded. The phrase “includes, but is not limited to . . . ” was added to the definitions for both Injury (Except Major) and Major Injury. The definition for Major Injury adds joint subluxation, internal organ injuries, amputations, spinal cord injuries, and crush injuries. It also replaces “closed head injuries with altered consciousness and subdermal hematoma” with the more generalized term “head injuries.” Lastly, the Major Injury definition also states that only traumatic bone fractures are included. The RAI User’s Manual clarifies that pathologic fractures are not considered a fall-related injury.
The most challenging aspect of the RAI User’s Manual text just cited is that it only offers a list of injuries to consider at three different levels but no actual definition for Injury (Except Major) or Major Injury. This omission thus relies on the nurse’s clinical judgment to determine the level of injury after reviewing the post-fall documentation. It requires concise assessment and documentation to describe the injury related to the fall. It also stipulates that reports from a resulting hospital or emergency department visit are added to the resident’s medical record.
Quality Measure Impact
The changes to the definition have a direct effect on when a resident will trigger for the fall with a major injury QM. For example, an assessment with an assessment reference date (ARD) before Oct. 1, 2025, would not have captured a fall that resulted from an overwhelming external force. If this event resulted in a major injury, it would not be coded as a fall-related injury because it was not considered a fall. However, for any assessment with an ARD on or after Oct. 1, 2025, the event would be deemed a fall. Any resulting injury would be considered to be related to the fall.
The impact of this change on the QMs will depend on how often a facility has falls related to an overwhelming external force. For example, if one facility had identified only one fall due to this cause in the 12 months before the update, the change described here would not result in a substantial difference in the measure. However, if the facility has experienced several falls related to overwhelming external force during the last year and has not resolved the root cause of these events, the staff may anticipate their QM increasing if this trend continues.
The change to the definition of major injury may also have an impact on QM outcomes. One positive change is the clear exclusion of pathologic fractures. The RAI User’s Manual clarifies on page J-39, “Fractures confirmed to be pathologic (vs. traumatic) are not considered a major injury resulting from a fall.” However, the expansion of the major injury examples allows for more injuries to be considered, possibly resulting in the capture of more fall-related injuries in this measure.
Differences Between MDS 3.0 and SNF QRP Falls with Major Injury Measures
Although the underlying MDS data and definitions are the same, the MDS 3.0 and SNF QRP Falls with Major Injury measures are not. Each QM has 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 determined is whether any exclusions would prevent the resident from inclusion in the calculation and the covariates that risk-adjust the calculation for some measures. The specifications for the two Falls with Major Injury measures are detailed in this chart:
| Measure Name | Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) | Application of Percent of Residents Experiencing One or More Falls with Major Injury (SNF QRP) |
| Measure Description | This measure reports the percentage of long-stay residents who have experienced one or more falls with major injury reported in the target period or look-back period. | This quality measure reports the percentage of Medicare Part A SNF stays in which one or more falls with major injury (includes bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) were reported during the SNF stay. |
| 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]). | The total number of Medicare Part A SNF stays (Type 1 SNF stays only) in the denominator with one or more look-back scan assessments that indicate one or more falls resulting in major injury (J1900C = [1, 2]). |
| Denominator | All long-stay SNF residents with one or more look-back scan assessments except those with exclusions. | The total number of Medicare Part A SNF stays (Type 1 SNF stays only) with one or more assessments that are eligible for a look-back scan (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 = [-]). | Medicare Part A SNF stays are excluded if: The number of falls with major injury was not coded; i.e., J1900C (Falls with Major Injury) = [-].The resident died during the SNF stay (i.e., Type 2 SNF stays). a. Type 2 SNF stays are SNF stays with a PPS [Prospective Payment System] 5-Day Assessment (A0310B = [01]) and a matched Death in Facility Tracking Record (A0310F = [12]). |
| Covariates | Not applicable | None |
| Source | MDS 3.0 QM User’s Manual | Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual Version 7.0 |
One of the key differences is the resident population of each measure. The MDS 3.0 measure includes all long-stay residents and all payer types, whereas the SNF QRP measure includes only residents on Medicare Part A stays in the facility. For the MDS 3.0 measure, a resident can only trigger the numerator one time, but in the SNF QRP measure, if the resident has multiple SNF stays within the 12-month period, each stay with a fall with major injury would trigger.
Quality Improvement
The recent changes are an opportunity to revisit the facility’s quality assurance and performance improvement (QAPI) process related to falls. The QAPI team should anticipate that QM trends may shift, not necessarily indicating that care has worsened, but because events and injuries previously excluded are now counted. It’s key for facility leaders to focus on the root cause of the falls and to address underlying system or process gaps while recognizing how overall trends may have shifted due to the changes.
To help ensure accurate reporting of falls and injuries related to falls, consistent post-fall assessment and documentation is essential. Because the RAI User’s Manual offers examples rather than a strict definition of major injury, the NAC must use clinical judgment to categorize the level of injury from the fall. Facility leaders may need to audit the current process, policies, and clarity of post-fall assessment and documentation. Gaps in this process, such as missing or vague documentation, should be addressed in QAPI as part of the team’s fall prevention strategies.
Conclusion
The updated definitions for falls and major injury changes how events are captured and how fall-related QMs trend. Understanding the differences between the MDS 3.0 and SNF QRP measures—and ensuring strong post-fall assessment and documentation—will help facilities interpret QM changes accurately and focus on effective fall prevention. For a more detailed discussion along with practical examples, NACs can attend Jessie McGill’s session “From Sand to Solid Ground: Strengthening Your Understanding of Falls and Major Injury” at the 2026 AAPACN Conference.
Reference
Centers for Medicare & Medicaid Services. (2025). Long-term care facility resident assessment instrument 3.0 user’s manual. https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual
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