Inaccurate MDS Coding of Resident Fall Status
Penalty
No penalty information released
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Summary
The facility failed to accurately code a resident's fall status on the Minimum Data Set (MDS) assessment. A resident with multiple diagnoses, including chronic kidney disease, heart failure, high cholesterol, hypertension, and overactive bladder, was documented in her most recent MDS quarterly assessment as having experienced a fall with major injury. However, a review of her medical record did not contain any documentation of such a fall. The DON confirmed that the resident had only one fall, which did not result in injury, and the MDS Coordinator acknowledged that the entry was likely an error. The facility's policy addressed how to correct MDS errors but did not prevent the initial inaccurate coding.