Percentage of Inpatient Rehabilitation Facility Patients Who Experience One or More Falls With Major Injury During Their Inpatient Rehabilitation Facility Stay

Identifying Attributes

Care Settings
Rehabilitation Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP)
Type of Quality Indicator
Outcome
IOM Quality Dimension
Safety
Domain
Adverse Events

Defining Attributes

Definition

Percentage of patients/residents who experience one or more falls with major injury during inpatient rehabilitation facility (IRF) stay.

Numerator

Total number of IRF stays in the denominator during the selected time window that experienced one or more falls that resulted in major injury: J1900C = [1] or [2].

Denominator

The total number of IRF stays with a discharge date in the measure target period, which do not meet the exclusion criteria.

Exclusions

An IRF stay is excluded if the number of falls with major injury was not coded at discharge: J1900C (Falls with Major Injury).

Use of Risk Adjustment
No
Risk Adjustments

None

Stratifications

None

Data Attributes

Type of Data Collection
Standardised clinical data
Data Collection Methods

Effective on October 1, 2022, the IRF-PAI Version 4.0 is used to collect and submit assessment data for the IRF QRP. Calculation for facility-level observed score: Divide the facility's numerator count (Step 3) by its denominator count (Step 2) to obtain the facility-level observed score, and then multiply by 100 to obtain a percent value.

Frequency of Data Collection
Quarterly
Frequency of Data Collection in Days
91
Reporting Methods

Internet Quality Improvement and Evaluation System (iQIES).

Reporting Frequency
Quarterly
Reporting Frequency in Days
91
Indicator Has Recommended Targets
Yes

Source and Reference Attributes

Evidence Source

Centers for Medicare & Medicaid Services (CMS), United States. Inpatient Rehabilitation Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual. Accessed August 3, 2023. Available from: www.cms.gov/files/document/irf-quality-measure-calculations-and-reporting-users-manual-v40.pdf.

Centers for Medicare & Medicaid Services (CMS), United States. Inpatient rehabilitation facilities - The Measures. Accessed August 3, 2023. Available from: data.cms.gov/provider-data/topics/inpatient-rehabilitation-facilities/measures.

Link to Measurement Tools

Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)

Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
Yes
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
No
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
12 March 2025