Two new reports from the HHS Office of Inspector General (OIG) released on September 15, 2025, examine the frequency and reporting of serious falls with major injury among Medicare-enrolled nursing home residents. The findings indicate that nearly half of these incidents were not reported as required in federally mandated assessments.
The first report, available here, found that nursing homes failed to report 43 percent of falls with major injury and hospitalization in Minimum Data Set (MDS) resident assessments. These assessments are used to calculate quality measures displayed on the Centers for Medicare & Medicaid Services’ (CMS) Care Compare website. The report noted that for-profit and chain-affiliated nursing homes, as well as larger facilities, were more likely to underreport falls. Underreporting was also more common among nonrural facilities and for falls involving younger residents, male residents, short-stay residents, and residents with only Medicare coverage.
Facilities with the lowest reported fall rates on Care Compare were also found to be the least likely to have reported falls examined in the review. According to the report, this indicates that some fall rates on Care Compare may reflect incomplete reporting rather than actual fall incidence. OIG recommended that CMS take steps to improve the completeness and accuracy of MDS data and consider applying similar efforts to other nursing home quality measures. CMS concurred with both recommendations.
The second report, a companion data snapshot, and available here, analyzed Medicare hospital claims and MDS assessments to identify and describe serious falls occurring between July 1, 2022, and June 30, 2023. During that period, there were 42,864 falls with major injury and hospitalization among Medicare-enrolled nursing home residents. A total of 1,911 residents died while hospitalized following a fall. Medicare and beneficiaries paid more than $800 million for related hospital care.
Most residents who experienced falls had previously been identified by nursing homes as having fall risk factors. Fall rates were highest among female residents, older residents, and those with short stays. Facilities with lower nurse staffing levels and lower quality ratings had higher fall rates. The report concluded that fall prevention and quality improvement initiatives could help reduce the incidence of serious falls among nursing home residents.
Compliance Perspective
Issue
Two OIG reports identified a high rate of underreporting of serious falls with major injury among Medicare-enrolled nursing home residents and noted that certain facility characteristics were associated with both increased fall rates and reduced reporting compliance. These findings raise concerns about the accuracy of MDS assessment data used for quality reporting and the need for effective fall prevention practices.
Discussion Points
- Facilities should review and strengthen policies and procedures related to fall reporting and fall prevention. This includes verifying that discharge assessments are completed within required timeframes and that reporting protocols align with federal MDS guidance. Facilities may also consider engaging external support to conduct targeted evaluations or mock reviews to assess current procedures and identify areas for improvement.
- Staff education can help reinforce proper reporting practices and awareness of fall risk factors. Regular training sessions that focus on assessment accuracy, documentation standards, and fall prevention strategies can support compliance with regulatory requirements and improve resident outcomes. Med-Net Academy offers fall prevention courses such as Falls Management, which covers fall response, investigation, and intervention planning, and Fall Prevention – Residents, Staff, Visitors, which addresses avoidable accidents, environmental hazards, and strategies to reduce risk across all facility areas.
- Routine audits of MDS data and fall-related documentation can help facilities ensure data accuracy and regulatory compliance. Facilities may find value in working with a consultant to conduct modified or focused reviews that align with areas identified through their QAPI process or recent survey outcomes.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*