P008: Division of Health Improvement/Health Certification Licensing and Oversight

P008: Percent of long-stay nursing home residents with falls with major injuries

3.0%FY 2017

Story Behind the Curve
  • About 50% of nursing home residents sustain a fall every year; of those who fall 10-25% are seriously injured. Falls often result in lost mobility, decreased quality of life, and increased mortality rate. 
  • Most falls with major injury eventually lead to an overall decline in activities of daily living, when residents can no longer walk or move around. Other medical complications can set in such as increase in depression, pneumonia, failure to thrive, and eventually, death. Many falls are preventable if preventive measures and risk assessments are implemented.
  • This measure reports the percentage of residents experiencing one or more falls with major injuries. Falls with major injury includes bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematoma. In 2017, the percentage of long stay nursing home residents with falls with major injuries was reported as 3%.
  • Falls are tracked through the Minimum Data Set (MDS) 3.0 data system, using a Quality Improvement and Evaluation System (QIES) workbench ad hoc report. Data reports are available 6-9 months after the year ends and is reported annually. The Division of Health Improvement (DHI) determines if reported falls should be investigated based on the severity of the allegation.
  • DHI partners with trade organizations to provide education and training to facilities on fall prevention to improve the health and well-being of residents.
  • This measure is explanatory; no target has been set for this measure.
Partners
  • New Mexico Nursing Home Association (NMNHA)
  • New Mexico Health Care Association (NMHCA)
  • HealthInsight
  • Centers for Medicare and Medicaid Services
What Works
  • Using real situations as examples allows DHI to tailor presentations and educational materials to proactively prevent falls in facilities.
  • Educating providers through trade organization presentations and talks, conference calls to allow administrators to hear the thought process behind citations, and providing materials on the web, and through trade organizations.
  • Having clear, simple and accessible processes for fall reporting.
  • Ensuring high quality, consistent and timely fall investigations are completed and deficient practices are corrected.
  • Collecting, tracking and analyzing data to identify trends and issues.
  • Reporting compliance to the public on the DHI website.
  • Comprehensive approaches that focus on identifying the many conditions that predispose a resident to falling, and addressing each resident's risk factors.
Strategy
  • Collaborate with NMNHA to conduct a live webinar to educate hospitals on reporting and investigating to improve the frequency and quality of self-reports from hospitals.
  • Collaborate with NMHCA  on self-reporting and conducting complaint investigations for nursing homes.
Action Plan
  • Q1:        
    • Continue to meet quarterly with NMHCA and HealthInsight to identify & discuss issues and provide information related to falls with injury. Completed.
  • Q2:        
    • DHI will meet with the NMHCA and HealthInsight to establish new goals and objectives. Completed.
    • Long Term Care (LTC) surveyors continue to enforce regulations related to falls and appropriate preventative measures during the recertification and/or complaint Nursing Home surveys. Completed.
    • MDS Coordinator continues to provide education and support to encourage accurate MDS coding related to falls with major injury. Completed.
    • Complaints Supervisor provides ongoing, as needed education to Nursing Home administration regarding the requirements to report falls with injury and required appropriate preventative measures.  Completed. 
  • Q3:
    • DHI will work with HealthInsight to explore using civil monetary penalty funded grants for fall prevention programs. Incomplete, start postponed.
  • Q4:
    • Approve and implement the fall prevention program statewide. Completed
    • LTC surveyors continue to enforce regulations related to falls and appropriate preventative measures during the recertification and/or complaint Nursing Home surveys. Completed
    • MDS Coordinator continues to provide education and support to encourage accurate MDS coding related to falls with major injury.  Completed
FY18 Annual Progress Summary
  • In FY17 DHI was successful in partnering with trade organizations to meet and provide trends data and best practices to health facilities on this initiative to reduce falls with major injuries in nursing homes. DHI will work and partner with trade organizations and other areas of NMDOH in continuing education and quality improvement actions for FY19.
Scorecard Result Program Indicator Performance Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy