Don’t Get Tripped Up: Leverage Live Data to Drive Quality Improvement and Prevent Falls
Originally published in NADONA’s The Director Quarterly Journal, Winter 2025 Issue.
The Centers for Medicare and Medicaid Services (CMS) publishes the Accident Critical Element Pathway to guide surveyors and facilities in identifying accident risks and implementing necessary interventions. Falls consistently rank among the top ten deficiencies cited during surveys. The Accident Critical Element Pathway aligns with regulations 483.25(d)(1), which mandates an environment free from hazards, and 483.25(d)(2), which requires adequate supervision and the use of assistive devices.
As part of the Protecting Access to Medicare Act of 2014 (PAMA), CMS is required to withhold 2% of Medicare fee-for-service Part A payments to skilled nursing facilities (SNFs) to fund the SNF Value-Based Purchasing (VBP) Program. The Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) measure was adopted in the SNF PPS Final Rule for FY 2024. The performance year for this measure will be FY 2027, using baseline data from FY 2023 (October 1, 2022, to September 30, 2023), while the performance period will occur in FY 2025 (October 1, 2024, to September 30, 2025). CMS continues to enforce the regulatory process with financial incentives aimed at reducing falls resulting in major injuries, encouraging facilities to prioritize fall prevention.
According to the Centers for Disease Control and Prevention (CDC), falls account for 3 million emergency department visits and 1 million hospitalizations annually. They are the leading cause of traumatic brain injuries (TBIs), with 83% of hip fracture deaths and 88% of hip fractured-related emergency visits in 2019 attributed to falls.
Drive Performance and Reduce Fall Risk with Key Health Data
Data analytics and key health information enable care providers to analyze large datasets, including risk factors and medication histories, to identify individuals at higher risk of falling. This allows for early interventions and preventative measures to reduce falls, particularly among adults aged 65 and older, both at home and in nursing facilities. However, the administrative burden on staff for documentation, Quality Assurance and Performance Improvement (QAPI), and follow-up can be significant, underscoring the importance of focusing on prevention and performance improvement.
As people age, changes in metabolism can alter how, medications are processed, increasing the risk of adverse effects. High risk medications that commonly contribute to falls include psychoactive drugs such as anticonvulsants, antidepressants, antipsychotics, benzodiazepines, opioids, and sedative-hypnotics. Cardiovascular medications, including antiarrhythmic, antihypertensives, and diuretics, can also increase fall risk by causing orthostatic hypotension (a drop in blood pressure upon changing positions, leading to dizziness) or syncopal episodes (loss of consciousness).
Despite these challenges, many individuals strive to remain active and independent, inadvertently increasing their risk of falls.
Address Fall Risks with Comprehensive Assessments and Individualized Care Plans
Several fall risk assessment tools predict risk, typically providing a basic snapshot for quick assessments, and allowing nursing staff to implement interventions based on identified risks. However, for SNFs to effectively address falls and falls with major injuries, a comprehensive review by the interdisciplinary team is necessary – one that goes beyond quick tools to identify individualized risk factors.
Serious outcomes of falls include TBIs, fractures, lacerations, mobility decline, and chronic pain. Simple measures, such as keeping pathways clear and ensuring good lighting, can help prevent falls. Routine eye exams and the use of safety devices like rails, non-slip mats, and mobility aids also reduce fall risk. Regularly discussing recent falls with resident’ friends, family, and caregivers, while considering factors like changes in mental status, dementia, confusion, and incontinence issues, can help identify causes such as urgency or embarrassment that may lead to falls.
So, how does having all this information help lower the risk? A comprehensive risk assessment, appropriate prescription of assistive devices, physical therapy for strengthening, and proper medication management –provided at the right time – enable SNFs to develop resident-centered care plans tailored to individual needs. Using comprehensive data, along with family input, helps identify fall trends and the timing of incidents, providing an accurate picture of the support needed. Keeping rooms free of clutter, well-lit, and aligning care with the resident’s usual routines allows staff to implement strengthening exercises, range-of motion activities, and restorative care to improve mobility and strength where needed.
Before residents arrive at a nursing facility, review their hospital fall risk assessment and conduct a second assessment upon arrival, as their risk and function may have changed during hospitalization. Developing a personalized care plan ensures the right equipment – such as safety rails, protective clothing, and mobility aids – is provided at the right time for the resident’s specific needs.
Leverage Data Analytics to Enhance Fall Prevention and Improve Resident Care
A system that processes large amounts of data can highlight key trends, such as fall patterns, the time of day, and the relationship to pain medications, other medications, or conditions like dementia or delusions. This allows SNFs to provide staff support and targeted education based on each resident’s specific needs, leading to more detailed and personalized care plans for prevention.
Injuries, such as fractures, not only have a physical impact but also cause emotional trauma, as many residents develop fear and anxiety about future falls, further impairing mobility and contributing to weakness. Fall victims often withdraw from social activities due to the fear of needing assistance. In addition to the physical toll, falls have significant mental and emotional consequences.
By leveraging data analytics, care teams can assist residents earlier and more holistically. Quality Improvement Plans (QIPs) are simplified by using technology to compare residents’ fall and mobility assessments over time, reviewing their Activity of Daily Living (ADL) documentation to monitor subtle declines, and identifying potential adverse drug events and changes in vital signs. Predictive analytics can process large volumes of data to identify actionable interventions, helping develop thorough QIPs and support ongoing process improvement (QAPI). These strategies enable facilities to monitor whether fall rates decrease as a result of specific interventions, and if not, adjust the care plan to be more resident-centered and targeted.
The impact of falls extends beyond the immediate injuries to residents, it also affects a facility’s financial success, regulatory status, and quality ratings – while increasing the potential for costly, long-term lawsuits. Data-driven strategies, comprehensive risk assessments, and personalized care plans can significantly reduce fall risk, improve outcomes, and enhance financial and regulatory performance – creating a safer, more supportive environment for older adults.
About the Authors
Kathy Derleth, RN, BSN | Clinical Program Director | Real Time Medical Systems
Kathy holds 40+ years of nurse leadership experience within long-term care. As a former chief nursing officer and VP of Clinical across many states, she guided clinical staff and facility nursing leadership on patient-centered care, clinical quality, and regulatory compliance. Kathy is an established conference educator and works collaboratively with several CMS Quality Improvement Organizations (QIO) for their current scope of work. She also serves as a member of the Pennsylvania Health Care Quality Committee.
MaryPat R. Carhart, MHA, BS, RN | Vice President of Clinical Services | Upstate Services Group, LLC
MaryPat is a Registered Nurse with over 40 years of healthcare experience as a clinician and leader in acute care, dialysis, long-term care, and managed care. She played a principal role in establishing a hemodialysis unit within a nursing home and developing policies for assisted living programs in skilled nursing facilities. As Vice President of Clinical Services at Upstate Services Group, MaryPat oversees strategic planning, clinical quality, education, and compliance. She leads a team of clinical consultants, guiding Administrators and Directors of Nursing on regulatory standards through mock surveys and audits. Known for her expertise in the Department of Health survey process, she is a sought-after educator on Avoidable Hospitalizations and Transitional Care in Post-Acute settings. MaryPat’s ability to educate and consult across clinical and management domains makes her a trusted resource for long-term care facilities.