Patient Safety Awareness Week: Reducing Falls and Rethinking Antipsychotic Use in Skilled Nursing
Each year, Patient Safety Awareness Week serves as an important reminder that protecting residents requires more than good intentions. It requires strong systems, clinical vigilance, and continuous improvement. In skilled nursing facilities, few issues are as closely tied to resident safety, regulatory oversight, and quality outcomes as falls.
At Health Advisory Partners by Aegis Therapies (HAP), we work alongside skilled nursing providers to strengthen clinical systems, reduce regulatory risk, and improve outcomes. In this blog we’ll discuss how Patient Safety Awareness Week is an ideal time to focus on fall prevention and responsible antipsychotic management.
Falls Take Center Stage in Federal Oversight
The Centers for Medicare & Medicaid Services (CMS) recently reinforced the importance of fall prevention through revisions to the Special Focus Facility (SFF) Program. CMS is strengthening oversight of the nation’s poorest-performing nursing homes, with renewed emphasis on fall prevalence among residents.
Key updates to the SFF program include:
Revised selection criteria that emphasize the prevalence of falls, alongside health inspection scores and staffing data
Clearer graduation standards to prevent repeated cycles of noncompliance
Escalating enforcement remedies for facilities that demonstrate continued noncompliance
Termination criteria for facilities cited with Immediate Jeopardy deficiencies on two surveys while in the program
Three-year post-graduation monitoring to ensure sustained compliance
For providers, this shift signals that falls are not just clinical events. They are regulatory risk markers and indicators of systemic performance.
The Medication Connection: Antipsychotics and Fall Risk
During patient safety awareness week, it is critical to examine contributing factors to falls, especially medication use.
Certain medications increase fall risk in older adults, including antipsychotics. According to the Mayo Clinic, antipsychotics, which are commonly prescribed for conditions such as schizophrenia and bipolar disorder, can increase the risk of orthostatic hypotension. This sudden drop in blood pressure upon standing can cause dizziness, instability, and ultimately falls.
In long-term care settings, antipsychotics are under increasing scrutiny because of both clinical side effects and quality reporting changes.
Long-Stay Antipsychotic Measure Updates
CMS is updating the long-stay antipsychotic quality measure to improve accuracy. The revised methodology will incorporate pharmacy claims, Medicare and Medicaid claims data, and Medicare Advantage encounter data to supplement MDS data. As outlined in the AAPACN webinarNew Year, New Measure: Making Sense of the Long-Stay Antipsychotic Re-Specification, this change addresses concerns from the Office of Inspector General that MDS data alone may not accurately reflect prescribing patterns.
Previously, the measure relied solely on MDS data and excluded certain diagnoses based only on MDS coding. The updated methodology:
Uses MDS plus pharmacy and claims data
Verifies diagnoses with claims support
Accounts for enrollment status
Excludes hospice residents based on claims
The expected impact is a rate increase from 14.64 percent to 16.98 percent due to more comprehensive data capture. Implementation, delayed from October 2025, is now scheduled for January 2026.
Systems Over Silos
Falls, medication management, staffing stability, and survey outcomes are interconnected indicators of clinical systems performance.
During Patient Safety Awareness Week, facilities should consider:
Are medication reviews proactively identifying fall-risk drugs?
Are non-pharmacologic interventions prioritized before initiating antipsychotics?
Is interdisciplinary communication strong enough to catch subtle changes in gait, cognition, or blood pressure?
Do quality assurance processes align with updated CMS oversight expectations?
Proactive fall reduction strategies, including careful antipsychotic stewardship, protect residents while reducing regulatory exposure and reputational risk.
Patient safety awareness week is an opportunity to move beyond compliance and focus on culture. When safety becomes a shared responsibility across clinical, operational, and leadership teams, fall prevention becomes a cornerstone of care excellence.
If your organization needs support strengthening fall prevention systems, preparing for survey scrutiny, or navigating the updated antipsychotic measure, contact Health Advisory Partners by Aegis Therapies (HAP) today.
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