Failure to Accurately Code Resident Fall in MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status, specifically by not coding a witnessed fall that occurred on 3/30/25. Record reviews showed that the resident, who had diagnoses including muscle wasting, lack of coordination, gait abnormalities, dementia, and Alzheimer's disease, experienced a fall that was documented in the incident log, care plan, and progress notes. The care plan and progress notes indicated that the fall was witnessed, and appropriate notifications and monitoring were documented at the time of the incident. Despite this documentation, the discharge MDS assessment did not indicate that the resident had experienced a fall since admission or prior assessment, as required by CMS's RAI Version 3.0 Manual. Interviews with facility staff confirmed that the fall should have been captured in the MDS, and its omission was attributed to a lack of communication between nursing staff and the MDS department. The MDS coordinator acknowledged that the fall was not coded and explained that this could result in incomplete information being communicated to subsequent care providers.