Step-by-Step Coding Guide for J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS)

1. Review of Medical Records

Begin by thoroughly reviewing the resident's medical records, including nursing notes, incident reports, therapy notes, and any other documentation that may indicate a fall or falls. Look for entries from the day of admission/entry or reentry up to and including the day before the Assessment Reference Date (ARD).

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). It includes intercepted falls.
• Intercepted Fall: A fall prevented by a person (caregiver) or a piece of equipment.

3. Coding Instructions

• Code 0, No Falls: If the resident had no falls since admission/entry or reentry or the prior assessment.
• Code 1, One Fall: If the resident had one fall since admission/entry or reentry or the prior assessment.
• Code 2, Two or More Falls: If the resident had two or more falls since admission/entry or reentry or the prior assessment.
• Code 3, No Information: If there is no information available on falls.

4. Coding Tips

• Ensure all sources of information are reviewed, including verbal reports from the resident, family, or staff.
• Consider all instances that meet the definition of a fall, regardless of the outcome or whether an injury occurred.

5. Documentation

Document each fall in the resident's medical record with details about the circumstances, interventions taken, and any injuries sustained. Ensure documentation is clear, accurate, and timely.

6. Common Errors to Avoid

• Failing to review all potential sources of information.
• Misinterpreting the definition of a fall and excluding certain types of falls.
• Overlooking intercepted falls.

7. Practical Application

Example: Mrs. Smith was admitted to the facility 30 days ago. The nursing notes reveal one documented fall 15 days after admission when she slipped from her chair but was caught by a staff member (intercepted fall). A week later, she tripped over her walker and landed on the floor without sustaining any injury.

Based on the coding instructions:

• Mrs. Smith would be coded as having "Two or More Falls" since admission, corresponding to Code 2 in J1900.

The Step-by-Step Coding Guide for item J1900 in MDS 3.0 Section J is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.