Step-by-Step Coding Guide for J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS)

1. Review of Medical Records

Start by reviewing the resident's medical records, focusing on any documentation of falls since admission, entry, or reentry, or since the last OBRA or Scheduled PPS Assessment. This includes nursing notes, incident reports, therapy notes, and physician orders. Look for descriptions of falls, interventions taken post-fall, and any medical evaluations or treatments provided as a result.

2. Understanding Definitions

Fall: An 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.

3. Coding Instructions

• Code 0 (No): If there have been no falls since admission/entry or reentry or the last OBRA or Scheduled PPS Assessment.
• Code 1 (Yes): If there has been one or more falls since admission/entry or reentry or the last OBRA or Scheduled PPS Assessment.

4. Coding Tips

• Include all types of falls, regardless of the circumstances or whether an injury was observed.
• Do not exclude falls that occurred outside of the facility, such as during outings or hospital visits.
• Consult with interdisciplinary team members who may have observed falls or have relevant information.

5. Documentation

Document the date, time, and circumstances of each fall, including the location, activities prior to the fall, and potential contributors (e.g., environmental factors, medical conditions). Record any injuries sustained and treatments provided. This documentation supports accurate coding and informs fall prevention strategies.

6. Common Errors to Avoid

• Failing to code a fall because it did not result in injury.
• Overlooking falls that occur in less supervised areas or during off-shift hours.
• Confusing assisted transfers or purposeful lowering to the ground by staff as falls.

7. Practical Application

Example: A resident has two falls within the assessment period. The first fall occurred in their room when trying to transfer from the bed to a wheelchair without assistance, resulting in no injury. The second fall happened in the bathroom, where the resident slipped on a wet floor, leading to a minor bruise.

Documentation: Record both falls in the medical record with detailed descriptions. Implement and document fall prevention interventions, such as increased supervision during transfers and ensuring bathroom floors are dry and free of hazards.

Coding for J1800: Code 1 (Yes) because the resident experienced falls during the specified period.