Inaccurate MDS Assessment Coding of Resident Falls
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status, specifically for one resident who experienced two falls during the assessment period. The discharge MDS assessment only documented one fall with a major injury, omitting a second fall that occurred without injury. Documentation in the resident's care plan and incident reports confirmed two separate falls: one from a wheelchair without injury and another resulting in a hip fracture. The MDS Coordinator confirmed that both falls should have been recorded in Section J of the MDS, but only one was captured. Interviews with facility staff revealed that MDS Coordinators are responsible for compiling information from various sources, including the electronic medical record, progress notes, and incident reports, to ensure accurate MDS coding. The MDS Coordinator who completed the inaccurate assessment was no longer employed at the facility. The facility's policy requires comprehensive assessments to be used in developing and revising person-centered care plans, and these assessments are to be maintained in the resident's active record. The failure to accurately code both falls on the MDS assessment resulted in an incomplete representation of the resident's care needs.