There is a focus on the insufficient OASIS documentation of major injuries resulting from falls at home for patients admitted to the hospital in the latest OIG report. The study discovered that in 55 percent of hospital admissions due to home falls with injury, often major, there was inadequate record on the OASIS. Strikingly, many instances revealed a complete absence of any OASIS document when the patient had been hospitalized.  

We have two key points to address. First, it’s necessary to complete OASIS Transfers whenever a patient is hospitalized for more than 24 hours, unless it’s for standard testing. In such cases, the Transfer OASIS, is completed, which includes items J1800 and J1900. These entries are used to document any falls and their severity.  

In the case of the transfer OASIS, suppose you discover on a Monday morning that a patient was rushed to the emergency room due to a fall on Saturday and subsequently admitted. You must complete and submit this Transfer OASIS to the OASIS database.  

The second key point is accuracy of completion of the items J1800 and J1900.  J1800 allows you to record that the patient experienced a fall. J1900 is used to document the severity of that fall. It details whether there was an injury related to the fall, if there was no injury, if there was an injury but not a major one, or if there was a major injury.   The Major Injury option on the OASIS includes bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematomas, which should be reported if they are the result of a fall. Additionally, any injury that resulted from a fall, not on the list of major injuries, should be recorded as Injury (Except Major) on the OASIS.  

The significant concern here is the OIG finding that 55% of major injuries resulting from falls were not accurately documented in the OASIS. Moreover, there were several instances where the OASIS not transmitted at all.  

We are certain that CMS will implement the OIG’s recommendations, which involve stricter scrutiny of agencies regarding their timely completion of OASIS and the accurate completion of the section on injuries resulting from falls.  

It’s crucial for your organization to provide OASIS training, particularly focusing on fall incidents, to ensure not just the completion of the Transfer OASIS but also their prompt submission to the OASIS database.  

At Healthcare Provider Solutions, we offer OASIS education through our 5-part OASIS-E Training Series and our Home Health Guide to OASIS: A Reference for Field Staff, 2023. To view the OIG report, please click here 

If there is anything HPS can ever do for you, don’t hesitate to reach out and let us know.

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