Failure to Accurately Reflect Resident Falls in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the fall history of two residents. For one resident with a history of hemiplegia and a non-ruptured cerebral aneurysm, the Annual MDS assessment did not document a fall without injury that occurred earlier in the year, despite nursing progress notes and post-fall reviews clearly indicating the incident. The resident was cognitively intact and required moderate assistance with transfers, and the fall was unwitnessed but resulted in no injury. Another resident, diagnosed with multi-system degeneration of the autonomic nervous system and Parkinsonism, experienced two falls without injury and one fall with a minor injury within the look-back period for her Quarterly MDS assessment. These incidents were documented in nursing progress notes, neuro checks, and post-fall reviews, including details of abrasions and pain complaints. However, the MDS assessment for this resident did not reflect any of these falls, despite the availability of supporting documentation in the medical record. Interviews with the Nurse Assessment Coordinator and the Director of Nursing revealed that the process for completing MDS assessments involved reviewing fall-related documentation, such as UDAs and neuro checks. The Nurse Assessment Coordinator acknowledged missing the falls in the MDS due to oversight and timing issues. The facility's policy required accurate and certified assessments by qualified professionals, with the MDS serving as the clinical basis for care planning and delivery. Despite the care plans being updated, the MDS assessments did not accurately capture the residents' fall histories as required.