Failure to Accurately Code Major Injury on Resident Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their clinical status, specifically regarding a fall with major injury. A male resident with a history of hemiplegia, hemiparesis, epilepsy, and reduced mobility experienced an unwitnessed fall in his room, resulting in a left leg fracture. Nursing notes documented the fall and subsequent injury, including swelling and the application of a brace. However, the resident's subsequent Quarterly MDS assessment did not indicate that a major injury had occurred, instead documenting that there had been no major injury since admission or the prior assessment, despite the definition of major injury including bone fractures. Interviews with facility staff revealed that the process for tracking and documenting falls relied heavily on the electronic medical record (EMR) system, which only flagged incidents that were marked as closed. The MDS Coordinator stated that if a fall incident was not closed in the EMR, it would not be included in the information used to complete the MDS assessment. In this case, the fall incident remained open for nearly two months, and as a result, the MDS assessment did not reflect the major injury. The absence of a Director of Nursing (DON) during this period contributed to lapses in oversight, as responsibilities were distributed among Assistant DONs and other staff. Further, the facility's administrative and clinical leadership described a process in which daily meetings were held to discuss incidents and update care plans, but there was no manual tracking system for falls, and the MDS Coordinators depended on the EMR's automated prompts. The compliance nurse and MDS Consultant were involved in reviewing documentation, but it was unclear if every assessment was checked for accuracy. Facility policy required that each assessment be conducted with appropriate participation from health professionals and that each individual certify the accuracy of their portion, but this process was not followed in this instance, resulting in an inaccurate assessment.