Inaccurate MDS Coding for Falls and Tobacco Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents. For one resident with a history of falls, medical records and progress notes documented two separate incidents where the resident was found on the floor in her room. However, the MDS for this resident was coded to indicate that no falls had occurred during the specified time frame. The MDS Coordinator confirmed during record review that these falls should have been coded as 'Yes' in section J1800, in accordance with the RAI Manual instructions. For another resident with diagnoses including osteomyelitis and vertebral fractures, a Safe Smoking Assessment Evaluation documented that the resident smoked cigarettes. Despite this, the MDS was coded to indicate that the resident did not use tobacco. The MDS Coordinator confirmed that section J1300 should have been coded 'Yes' to reflect current tobacco use, as supported by the resident's assessment and the RAI Manual guidelines.