Failure to Accurately Code Falls in Resident Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their status, specifically regarding falls. Record review showed that the resident, who had Alzheimer's disease, muscle weakness, lack of coordination, and hemiplegia/hemiparesis, experienced multiple falls as documented in the care plan and incident log. Despite these documented falls, the resident's most recent quarterly MDS assessment did not indicate any falls since admission or the prior assessment. Interviews with facility staff, including the ADON, DON, and MDS coordinator, confirmed that the MDS assessment was inaccurately coded and did not capture the resident's falls. The staff acknowledged that the MDS should have been updated to reflect the falls, and that the failure to do so could result in the MDS not triggering appropriate interventions for fall risk. The MDS nurse responsible for the inaccurate assessment was no longer employed at the facility. Facility policy and CMS RAI Manual guidelines require that MDS assessments consistently reflect information from progress notes, care plans, and resident observations. In this case, the MDS assessment did not align with the documented incidents and care plan interventions, resulting in an inaccurate representation of the resident's fall history.