Inaccurate MDS Assessment Following Resident Fall with Major Injury
Penalty
No penalty information released
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Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident who experienced a fall with major injury. The resident was pushed in a wheelchair by a Certified Nursing Assistant, during which the resident's feet became caught under the wheelchair, resulting in a fall and head injury. The resident subsequently complained of neck pain, had elevated blood pressure, and was transferred to the hospital, where a cervical spine fracture was diagnosed and a cervical collar was prescribed. Despite these events, the MDS assessment completed after the incident did not document the fall or the major injury, as confirmed by the MDS Coordinator, who acknowledged the omission and was unsure how the error occurred.