Inaccurate MDS Coding for Falls and Discharge Location
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for two residents. One resident, with a history of traumatic brain injury and functional quadriplegia, experienced a fall when his wheelchair slid out from under him while it was not locked. Despite this incident being documented in the medical record, the subsequent quarterly MDS assessment did not reflect the fall. In another case, a resident who was discharged from the facility was incorrectly coded in the MDS as having an unplanned discharge to the hospital, when in fact, documentation and staff interview confirmed the resident left to live with his daughter. These inaccuracies were verified through staff interviews and record reviews.