Is this a Fall with Major Injury? A resident had an unwitnessed fall and self-reported that she hit her head. No injuries or concerns were noted upon post-fall evaluations. Three days later, the resident was transferred to the hospital due to chest pain and non-reactive pupils. Diagnostic imaging showed a subdural hematoma. Should this be reported on the MDS as a fall with major injury?
If the injury cannot be attributed to any other event, it should be considered a fall-related injury. According to the RAI, an injury related to a fall is defined as “Any documented injury that occurred as a result of, or was recognized within a short period of time (e.g., hours to a few days) after the fall and attributed to the fall.” Symptoms of a subdural hematoma may appear immediately following trauma to the head, or they may develop over time – even weeks to months. Facility policies and procedures for post-fall management should include the evaluation of neurological status for an individual whose fall is unwitnessed or self-reported, as well as those known or suspected to have hit their head.