Inaccurate Coding of Falls on MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents. For one resident, multiple progress notes documented incidents where the resident was found on the floor, including being observed sitting or lying on the floor in his room or doorway, sometimes with minor redness noted but no significant injuries. Despite these documented falls, the resident's quarterly MDS assessment indicated that there had been no falls since the prior assessment. Similarly, another resident's record showed two separate incidents where the resident was found on the floor, one time after sliding out of a wheelchair and another after attempting to stand and losing balance. Both incidents were documented in progress notes, with no significant injuries reported. However, the resident's quarterly MDS assessment also indicated no falls since the prior assessment. Interviews with the MDS Coordinator revealed that she only reviewed active risk management reports and was unaware that historical reports could be accessed, while the DON clarified that prior reports were available under a different tab. The facility did not have a specific policy for MDS assessments.