J1700: Fall History on Admission/Entry or Reentry

Item Rationale

Health-related Quality of Life

• Falls are a leading cause of injury, morbidity, and mortality in older adults.

• 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.

• Persons with a history of falling may limit activities because of a fear of falling and should be evaluated for reversible causes of falling.

Planning for Care

• Determine the potential need for further assessment and intervention, including evaluation of the resident’s need for rehabilitation or assistive devices.

• Evaluate the physical environment as well as staffing needs for residents who are at risk for falls.

Steps for Assessment

The period of review is 180 days (6 months) prior to admission, looking back from the resident’s entry date (A1600).

1. Ask the resident and family or significant other about a history of falls in the month prior to admission and in the 6 months prior to admission. This would include any fall, no matter where it occurred.

2. Review inter-facility transfer information (if the resident is being admitted from another facility) for evidence of falls.

3. Review all relevant medical records received from facilities where the resident resided during the previous 6 months; also review any other medical records received for evidence of one or more falls.

Coding Instructions for J1700A, Did the Resident Have a Fall Any Time in the Last Month Prior to Admission/Entry or Reentry?

• Code 0, no: if resident and family report no falls and transfer records and medical records do not document a fall in the month preceding the resident’s entry date item (A1600).

• Code 1, yes: if resident or family report or transfer records or medical records document a fall in the month preceding the resident’s entry date item (A1600).

• Code 9, unable to determine: if the resident is unable to provide the information or if the resident and family are not available or do not have the information and medical record information is inadequate to determine whether a fall occurred.

Coding Instructions for J1700B, Did the Resident Have a Fall Any Time in the Last 2-6 Months prior to Admission/Entry or Reentry?

• Code 0, no: if resident and family report no falls and transfer records and medical records do not document a fall in the 2-6 months prior to the resident’s entry date item (A1600).

• Code 1, yes: if resident or family report or transfer records or medical records document a fall in the 2-6 months prior to the resident’s entry date item (A1600).

• Code 9, unable to determine: if the resident is unable to provide the information, or if the resident and family are not available or do not have the information, and medical record information is inadequate to determine whether a fall occurred.

Coding Instructions for J1700C. Did the Resident Have Any Fracture Related to a Fall in the 6 Months prior to Admission/Entry or Reentry?

• Code 0, no: if resident and family report no fractures related to falls and transfer records and medical records do not document a fracture related to fall in the 6 months (0-180 days) preceding the resident’s entry date item (A1600).

• Code 1, yes: if resident or family report or transfer records or medical records document a fracture related to fall in the 6 months (0-180 days) preceding the resident’s entry date item (A1600).

• Code 9, unable to determine: if the resident is unable to provide the information, or if the resident and family are not available or do not have the information, and medical record information is inadequate to determine whether a fall occurred.

Examples

1. On admission interview, Resident J is asked about falls and says they have "not really fallen." However, they go on to say that when they went shopping with their child about 2 weeks ago, their walker got tangled with the shopping cart and they slipped down to the floor.

Coding: J1700A would be coded 1, yes.

Rationale: Falls caused by slipping meet the definition of falls.

2. On admission interview a resident denies a history of falling. However, their child says that they found their parent on the floor near their toilet twice about 3–4 months ago.

Coding: J1700B would be coded 1, yes.

Rationale: If the individual is found on the floor, a fall is assumed to have occurred.

3. On admission interview, Resident M and their family deny any history of falling. However, nursing notes in the transferring hospital record document that Resident M repeatedly tried to get out of bed unassisted at night to go to the bathroom and was found on a mat placed at their bedside to prevent injury the week prior to nursing home transfer.

Coding: J1700A would be coded 1, yes.

Rationale: Medical records from an outside facility document that Resident M was found on a mat on the floor. This is defined as a fall.

4. Medical records note that Resident K had hip surgery 5 months prior to admission to the nursing home. Resident K’s child says the surgery was needed to fix a broken hip due to a fall.

Coding: Both J1700B and J1700C would be coded 1, yes.

Rationale: Resident K had a fall related fracture 1–6 months prior to nursing home entry.

5. Resident O’s hospital transfer record includes a history of osteoporosis and vertebral compression fractures. The record does not mention falls, and Resident O denies any history of falling.

Coding: J1700C would be coded 0, no.

Rationale: The fractures were not related to a fall.

6. Resident P has a history of a “Colles’ fracture” of their left wrist about 3 weeks before nursing home admission. Their child recalls that the fracture occurred when Resident P tripped on a rug and fell forward on their outstretched hands.

Coding: Both J1700A and J1700C would be coded 1, yes.

Rationale: Resident P had a fall-related fracture less than 1 month prior to entry.

DEFINITION

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). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall, no matter whether it occurred at home, while out in the community, in an acute hospital or a nursing home. Falls are not a 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. CMS understands that challenging a resident’s balance and training them to recover from a loss of balance is an intentional therapeutic intervention and does not consider anticipated losses of balance that occur during supervised therapeutic interventions as intercepted falls.

FRACTURE RELATED TO A FALL

Any documented bone fracture (in a problem list from a medical record, an x-ray report, or by history of the resident or caregiver) that occurred as a direct result of a fall or was recognized and later attributed to the fall. Do not include fractures caused by trauma related to car crashes or pedestrian versus car accidents or impact of another person or object against the resident.