Inaccurate MDS Coding for Resident Fall Event
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident reviewed for accidents. Specifically, the MDS Quarterly Assessment coded the resident as having experienced a fall with injury, despite documentation in nurse notes and pain assessments indicating that the resident had no pain and no physical injury following the fall. The facility's matrix also incorrectly indicated a fall with injury for this resident. Further review of the care plan and progress notes confirmed that the resident did not report pain and had no injury on multiple assessments following the incident. An x-ray ordered after the resident reported arm pain was negative for fracture. Interviews with the Nursing Home Administrator and the MDS Coordinator confirmed that the MDS was coded incorrectly, as the resident did not have a fall with injury. The MDS Coordinator acknowledged that the assessment was inaccurate, as pain and injury were not present according to the documentation. The deficiency was discussed with the administration team during the exit conference.