Measure Information Form

Measure Set: Assisted Living Community (ALC)

Set Measure ID: ALC-02

Performance Measure Name: Resident Falls

Description: Number of residents who fall and are transferred to the hospital.

Rationale: The effort to monitor the prevalence of falls at the facility level with transfer to the hospital is very important for protecting the health of facility residents. Studies show that such falls can leave up to 50% of those aged 60 years and older with fears that impact both their functional abilities and social activities (García-Martínez et al., 2024). Identifying falls risk factors can help facilities reduce incidence of falls among their residents through clinical and non-clinical practices (CDC, 2016). Falls account for about 3 million emergency department visits each year among elderly people (CDC, 2024).

Type Of Measure: Outcome

Improvement Noted As: Decrease in the rate

Numerator Statement: Residents who fall and are transferred to the hospital, per month.

Included Populations: Not applicable
Excluded Populations: Not applicable
Data Elements:

Fall With Transfer to Hospital

Denominator Statement: Number of residents who resided in the community on the last day of the month.

Included Populations: Not applicable
Excluded Populations: Not applicable
Data Elements:

Assisted Living Community Resident

Risk Adjustment: No.

Data Collection Approach:

Denominator: The total number from the data element Assisted Living Community Resident is the Denominator.

This number will be entered into the Direct Data Submission Platform (DDSP) tool.

Numerator: Count the number of residents with a 'Yes' to the data element Fall With Transfer to Hospital; the total number is the numerator.

This number will be entered into the Direct Data Submission Platform (DDSP) tool.

Example: You are abstracting cases for the month of August. On August 31st there are 85 residents living at the assisted living community. Your denominator will be 85. When you look back through the 85 resident’s records, there were 4 residents that fell and were transferred to the hospital. Your numerator will be 4.

Denominator = 85
Numerator = 4

Data Accuracy: None

Measure Analysis Suggestions: None

Sampling: No.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Centers for Disease Control and Prevention. (2016). Behavioral Risk Factor Surveillance System (BRFSS) data. Retrieved from https://www.cdc.gov/steadi/
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2024). Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. Retrieved March 11, 2024, from https://wisqars.cdc.gov/
García-Martínez, A., García-Rosa, S., Gil-Rodrigo, A., et al. (2024). Prevalence and outcomes of fear of falling in older adults with falls at the emergency department: A multicentric observational study. European Geriatric Medicine, 15(6), 1281–1289. https://doi.org/10.1007/s41999-024-00992-1

Measure Algorithm:
Graphic depiction of the Measure Algorithm. Refer to the Algorithm Narrative for each detailed step.

ALC-02: Resident Falls Algorithm Narrative

Numerator: Residents who fall and are transferred to the hospital, per month.
Denominator: Number of residents who resided in the community on the last day of the month.

1. Start processing and proceed to set Denominator.

2. Set Denominator equal to Assisted Living Community Resident.

Set Assisted Living Community Resident as denominator. Continue processing and proceed to Review each resident’s record.

3. Review each resident's record.

Review each resident’s record. Continue processing and proceed to Fall with Transfer to Hospital.

4. Check Fall with Transfer to Hospital.

If Fall with Transfer to Hospital equals “N”. Stop processing.
If Fall with Transfer to Hospital equals “Y”. Continue processing and proceed to Set Numerator.

5. Set Numerator.

Set Numerator equal to the count of residents with Fall with Transfer to Hospital equal to “Y”. Stop processing.

Measure Information Form ALC-02

Assisted Living Community Measures (v2026A)
Applicable 01-01-26 (1Q26) through 06-30-2026 (2Q26)