Inaccurate MDS Coding for Restraint Use
Penalty
No penalty information released
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Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident regarding restraint use. Record review showed that the resident was admitted with diagnoses including diabetes mellitus and lower limb amputations. The resident's December 2024 physician's orders did not include any order for a restraint. However, the annual MDS assessment for the resident indicated the use of a trunk restraint in a chair or out of bed. During an interview and record review, the staff member responsible for MDS confirmed that there was no order for a restraint and acknowledged that the assessment was incorrectly coded to indicate restraint use.