Inaccurate MDS Coding for Resident Falls
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of two residents. For one resident with diagnoses including COPD, end stage renal disease, and difficulty walking, clinical records showed a fall with no injuries occurred. However, the resident's Minimum Data Set (MDS) assessment did not document this fall, indicating inaccurately that no falls had occurred since the prior assessment. This discrepancy was confirmed during staff interviews. Another resident, with a history of muscle weakness, difficulty walking, and traumatic brain injury, experienced a fall with injury and was sent to the emergency room. Despite this, the resident's MDS assessment also failed to document the fall, incorrectly stating that no falls had occurred since the previous assessment. Staff interviews confirmed the inaccuracy in the MDS coding for this resident as well.