Inaccurate MDS Coding for Restraints
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status concerning restraints for two residents. Resident R9, who was admitted with diagnoses of schizophrenia, anxiety, and dementia, was inaccurately documented in the Minimum Data Set (MDS) as having a chair that prevents rising, used less than daily. However, observations revealed that Resident R9 was ambulating freely, and interviews with the Nursing Home Administrator and Director of Nursing confirmed that the facility was restraint-free and the MDS was coded inaccurately. Similarly, Resident R38, with diagnoses including anxiety disorder and non-Alzheimer's dementia, was documented in the MDS as using a limb restraint in a chair or out of bed, used less than daily. Observations showed that Resident R38 had no restraints, and there was no physician order for restraints. Interviews with the resident and facility staff confirmed that the resident never had any restraints, and the MDS was inaccurately coded. These inaccuracies in the MDS assessments led to the deficiency findings.
Plan Of Correction
MDS has been corrected for R9 and R38. MDS coordinators or designees will audit all current MDS's to ensure there are no further discrepancies. MDS coordinators will be in-serviced by NHA or designee on importance of assessment accuracy. MDS audits will be conducted by MDS coordinators or designees to ensure assessment accuracy monthly for 3 months, then quarterly thereafter. Results will be reported in QA.