Inaccurate MDS Assessment Documentation for Restraints and Falls
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments to reflect the actual status of seven residents. Specifically, the MDS Section P0100A, which documents the use of restraints such as bed rails, was incorrectly coded for several residents. Although the MDS indicated that bed rails were used daily as restraints, observations revealed that only quarter-sized rails were present, which staff confirmed were not used as restraints. Additionally, for one resident, the MDS Section J1900 was incorrectly coded to show zero falls with major injury, despite documentation of a fall resulting in a head injury and hospital transfer. Another resident was coded as not using a trunk restraint, even though a pelvic safety device was observed in use per physician order. These inaccuracies were confirmed through review of clinical records, physician orders, incident reports, direct observations, and staff interviews. The Director of Nursing and the Nursing Home Administrator both acknowledged the incorrect MDS coding for the affected residents. The deficiencies involved residents with complex medical histories, including epilepsy, bipolar disorder, anxiety, heart disease, paraplegia, pressure ulcers, hemiplegia, diabetes, psychotic disorder, and profound intellectual disabilities. The failure to accurately document the use of restraints and falls in the MDS assessments constitutes a violation of medical records requirements.