Agencies have new official guidance when responding to falls and falls with major injury in the OASIS.
 
The new errata for the OASIS-E1 Guidance Manual address updates to scoring J1800 (Any falls since SOC/ROC) and J1900 (Number of falls since SOC/ROC).
 
The changes follow a 2023 OIG report noting that more than half of all falls with major injury went unreported in the OASIS.
 
The additions at J1800 include:
  • A fall due to an overwhelming external force (e.g. a patient pushes another patient) would be considered a fall.
  • If a major injury results from a fall or an intercepted fall that occurs when a clinician is intentionally challenging a patient’s balance during balance training, it would be reported as both a fall and a major injury in J1800 and J1900.
At J1900, the updates include:
  • Adds “but is not limited to” when describing falls with a major injury. The examples are also updated to include: traumatic bone fractures, joint dislocations/subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries and crush injuries.
  • Fractures confirmed to be pathologic (vs traumatic) are not to be considered a major injury resulting from a fall.
The errata includes new examples when scoring falls and falls with major injuries.
 
CMS has also announced an update to the Falls With Major Injury quality measure, expanding the documentation review for the measure to go beyond OASIS reporting and review hospital and ER records.
More information:
See the OASIS-E1 Guidance Manual errata at cms.gov.
 
See a fact sheet on the changes as presented in the draft OASIS-E2 Guidance Manual at homehealthline.com.
 
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