Underreporting of Fall Injuries, Pressure Ulcers Associated with Racial, Ethnic Composition of Nursing Homes


These findings suggest that disparities in reporting data may be present in nursing homes, with implications for surveillance of nursing homes, priority setting for facilities, as well as payment and research.

Prachi Sanghavi, PhD

Credit: health.uchicago.edu

Prachi Sanghavi, PhD

Credit: health.uchicago.edu

Major injury falls and pressure ulcers—2 key quality measures of nursing facilities—are widely underreported and particularly so for specific racial and ethnic groups in nursing homes, according to recent study results.1

This new study’s investigators sought to address questions such as how widespread underreporting may be, whether certain nursing homes are more likely to underreport, and if facilities underreport across all indicators.

This research, authored by Prachi Sanghavi, PhD, from the Department of Public Health Sciences’ Biological Sciences Division at the University of Chicago.

“Quality measures have long generated suspicion, and recent work by Sanghavi et al. and Chen et al. found substantial underreporting nationally on at least some quality indicators,” Sanghavi and colleagues wrote.2

Overall, the team aimed to examine the relationship between reporting major fall injuries and reporting pressure ulcers within nursing homes. While prior research has explored the associations between racial and ethnic groups and these conditions, the potential impact of institutional racism on reporting practices in nursing homes had not been extensively investigated.

Background and Findings

The study’s investigators conducted a quality improvement study, using hospitalization data for Medicare fee-for-service beneficiaries between January of 2011, and December of 2017. The research team sought to examine the reporting rates of major injury falls and pressure ulcers by nursing homes using linked hospital admission claims and Minimum Data Set (MDS) assessments at the resident level.

Facility characteristics and the distribution of reporting across nursing facilities were analyzed by the investigators. The association between reports of both major fall injuries and pressure ulcers within these homes was assessed, and any potential racial and ethnic disparities influencing the associations were investigated.

The research team made exclusions for smaller facilities and onrs not consistently included in the sample throughout the study period. The team’s analyses were conducted in 2022, and the main outcomes they assessed were nursing home-level MDS reporting rates for falls and pressure ulcers, stratified by long-stay vs short-stay population or by race and ethnicity.

Overall, the investigators evaluated a sample of 13,179 nursing facilities in total, in which a total of 131,000 residents were found to have experienced hospitalizations as a result of pressure ulcers or major fall injuries. The residents had a mean age of 81.9 years, with females making up 71.0% and 81.1% being White.

Among the hospitalizations they found, the team noted 98,669 cases of major injury falls, of which 60.0% had actually been reported. Additionally, they found there were 39,894 hospitalizations for stage 3 or 4 pressure ulcers, with a reporting rate of 67.7%.

One major conclusion was that the investigators found widespread underreporting for both conditions, with 69.9% and 71.7% of nursing homes having reported at a rate of 80% for major injury falls and pressure ulcers, respectively.

Lower reporting rates were observed across a variety of facility characteristics, except, notably, for racial and ethnic composition. Nursing homes with high fall reporting rates were found to have a substantially higher proportion of White residents (86.9% vs. 73.3%), while those with high pressure ulcer reporting rates had fewer White residents (69.7% vs. 74.9%).

This pattern extended within nursing homes, as the association between the two reporting rates showed a slope coefficient of -0.42 (95% CI, -0.68 to -0.16). In other words, nursing homes with a higher proportion of White residents tended to show higher reporting rates for major fall injuries and lower rates for pressure ulcers.

“Even with alternative data sources, the study found that interpretation of quality measures needs to consider the racial and ethnic composition of nursing homes, which may affect both the prevalence of major injury falls and pressure ulcers and the accuracy of reporting,” they wrote.


  1. Sanghavi P, Chen Z. Underreporting of Quality Measures and Associated Facility Characteristics and Racial Disparities in US Nursing Home Ratings. JAMA Netw Open. 2023;6(5):e2314822. doi:10.1001/jamanetworkopen.2023.14822.
  2. Chen Z, Gleason LJ, Sanghavi P. Accuracy of pressure ulcer events in US nursing home ratings. Med Care. 2022;60(10):775-783. doi:10.1097/MLR.0000000000001763.
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