Failure to Accurately Document Falls in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the fall history of three residents. For one resident with diagnoses including congestive heart failure and muscle weakness, two unwitnessed falls that occurred on the same day were documented in the care plan and nurses' notes, but were not recorded in the annual MDS assessment. Interviews with the DON and Director of Reimbursement confirmed that these falls should have been included in the MDS, and that omission could impact care planning. Two additional residents with multiple falls documented in care plans and the facility's accident and incident logs also had MDS assessments that either left the fall history section blank or incorrectly coded no falls since admission or the prior assessment. These inaccuracies were confirmed through record review and staff interviews, with staff acknowledging that the MDS should have reflected the residents' fall history as documented elsewhere in their records.