Inaccurate MDS Coding for Falls with Major Injury
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident reviewed for falls with major injury. The MDS assessment indicated that the resident had experienced two falls with major injuries since the prior assessment, despite a review of unwitnessed fall reports and electronic healthcare records showing no documentation of any major injuries from falls during the relevant period. Staff interviews, including those with the DON and an LPN, confirmed that there was no knowledge or evidence of major injuries resulting from falls for this resident. The resident in question had a moderate cognitive loss, bilateral lower body functional impairment, and required assistance for mobility and transfers. The MDS listed several active diagnoses, including type two diabetes mellitus with neuropathy, anemia, arthritis, thyroid disorder, and non-Alzheimer's dementia. Despite these conditions, all available documentation and staff interviews indicated that the resident had not sustained any major injuries from falls, suggesting the MDS was inaccurately coded regarding falls with major injury.