If you have a loved one in a nursing home, you probably check public ratings and safety measures to choose a facility and to sleep a little easier at night. A new federal watchdog review says that comfort may be misplaced. The Office of Inspector General found that many U.S. nursing homes are not reporting residents’ serious fall-related injuries as required, which hides the true scope of harm and distorts quality scores that families and payers rely on. The investigators conclude that the national reporting system for serious incidents in long-term care is fragmented, inconsistently enforced, and open to gaming.
Falls are already a leading threat to older adults. National data show that about one in four Americans age 65 and older falls each year, and falls are a top cause of injury for this group. When nursing home falls that lead to emergency visits or hospitalizations do not appear in public reporting, families lose a clear view of risk and regulators lose sight of where problems are concentrated.
What the OIG Analyzed
The OIG examined Medicare claims for emergency department visits and hospital stays linked to falls and fractures among residents of skilled nursing facilities. Those records were compared with the facilities’ required incident reports, Minimum Data Set submissions that feed public quality measures such as “falls with major injury,” and state survey agency logs of serious incidents and immediate jeopardy events. The review spanned multiple years and looked for patterns by ownership type, chain affiliation, state, and the Centers for Medicare & Medicaid Services Five-Star quality ratings. The goal was to see whether hospital-coded injuries matched what facilities and states said had occurred.
Key Findings on Underreporting
Investigators found significant underreporting of serious falls. A large share of hospital-treated falls originating in nursing homes did not show up in state survey systems and were not coded as major-injury falls in the MDS. The gaps were present in both for-profit and nonprofit homes, with especially notable discrepancies in certain chains and states. The missing reports were most common for unwitnessed falls, especially at night or during shift changes, and for head injuries and hip fractures in residents with dementia or mobility limits.
Underreporting was also more likely around transitions of care. Incidents that occurred soon after admission or during transfers were less likely to be captured in the data that shape public measures. As a result, facilities’ publicly reported “falls with major injury” rates are materially understated in many cases. That understatement can inflate Five-Star ratings and mislead families, hospitals, and health plans that use those scores to gauge quality and risk.
How Reporting Breaks Down
The OIG points to several weak links in the reporting chain. Internal incident logs are often incomplete or not escalated to state agencies when rules require it. Hospitals commonly code fall-related injuries in claims, yet they do not consistently alert state surveyors or the resident’s facility in a way that automatically triggers required reports. Differences in timelines and definitions of what counts as a serious bodily injury create confusion and loopholes. When every entity uses a slightly different clock and vocabulary, events slip through the cracks.
Why Facilities Miss the Mark
Ambiguity in rules means facilities vary in how they interpret when a fall must be reported externally versus documented only in internal systems or the MDS. Misaligned incentives play a role as well. Public measures and star ratings tie directly to reputation and payment, which creates pressure to minimize reportable incidents and to avoid citations, penalties, or lawsuits. Workforce challenges compound the problem. Chronic staffing shortages, turnover, and limited training on incident recognition and reporting slow down or deter accurate documentation. Many facilities still juggle paper forms or incompatible software, and hospitals, nursing homes, state agencies, and CMS often operate in data silos that do not automatically reconcile claims and incident reports.
Real-World Consequences
The first harm falls on residents. When a serious fall is not reported and investigated, teams miss the chance to conduct root-cause analysis and to update care plans, such as adjusting supervision levels, reviewing medications, or adding mobility aids. That raises the risk of repeat injuries. Transparency also suffers. Families cannot reliably compare facilities when public data are incomplete, and regulators lack a full picture to target oversight and quality improvement. The financial impact is not trivial. Medicare pays for hospital care that can stem from preventable hazards, while facilities that underreport may face fewer consequences than those that play by the rules.
How Stakeholders Are Responding
CMS and the Department of Health and Human Services acknowledge gaps between hospital claims and facility-reported data and say they will evaluate rule clarifications, improved guidance, and better integration across systems. Industry leaders respond that many falls are clinically unavoidable in frail residents with complex needs and point to staffing shortages, reimbursement pressures, and regulatory complexity as root causes of reporting lapses. Some question whether all hospital-coded falls should be treated as proof of a reportable incident. Patient advocates and long-term care ombudsmen call for stronger enforcement, clearer rules, and greater transparency for families. Lawmakers have signaled interest in oversight hearings, data-sharing mandates, and standardizing reporting with tighter penalties for noncompliance.
What the OIG Recommends
The watchdog urges agencies to clarify and harmonize requirements by standardizing definitions of serious injury and reportable events and aligning MDS coding with incident reporting and state survey expectations. It also recommends automating data reconciliation, so hospital claims can be crosswalked with facility records to flag likely unreported falls, and requiring hospitals to electronically notify states and facilities when they treat a nursing home resident for a fall-related injury. Enforcement should be strengthened with targeted surveys of facilities that show mismatches, scaled penalties for persistent gaps, and potential adjustments to Five-Star scores. Training and technology support for frontline staff, along with public dashboards that highlight discrepancies by facility, state, and chain, round out the plan.
Snapshots That Illustrate the Problem
Consider a resident with dementia who sustains a hip fracture from an unwitnessed fall at night. The hospital treats the injury and sends the person back, but the facility logs it only internally and neither codes it as a major injury in the MDS nor reports it to state officials. In another case, a new resident falls within 48 hours during a transfer. Staff attribute the event to resident behavior, no external report is filed, and the required root-cause analysis never occurs. At the chain level, a facility might tout low public fall rates, while claims data show frequent hospitalizations for fractures tied to that location.
What Families Can Do Now
While policymakers work on fixes, families can press for clarity and vigilance. Ask how the facility prevents falls, how staff identify high-risk residents, and how quickly care plans are updated after an incident. Request details on night staffing, handoffs during shift changes, and how the facility handles the first 72 hours after admission when risk is high. Inquire how leaders reconcile hospital visits with internal incident logs and MDS coding, and whether you will receive same-day notification if your loved one is sent to the emergency department for a fall. Finally, ask about practical supports such as physical therapy, toileting schedules, environmental modifications, and assistive technologies that reduce risk without relying on restraints.
If ratings are to mean what families think they mean, the numbers must reflect the injuries residents actually experience. The OIG’s message is clear: better definitions, integrated data, stronger enforcement, and transparent reporting can move nursing home care closer to that goal.
