Inaccurate MDS Fall Documentation for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the fall history of a resident with severe cognitive impairment and multiple medical diagnoses, including a left femur fracture, adult failure to thrive, and chronic atrial fibrillation. Despite documented falls occurring on several dates, the MDS assessments for this resident repeatedly indicated that no falls had occurred since admission or the prior assessment. Specifically, the MDS assessments with Assessment Reference Dates (ARDs) of 04/11/2025, 05/05/2025, and 07/08/2025 all recorded 'No' for the question regarding falls, even though incident reports and the electronic medical record documented falls on 03/13/2025, 04/17/2025, 06/13/2025, and 06/17/2025. As a result, follow-up questions regarding the extent of injury from falls were not activated in the MDS, leading to incomplete documentation of the resident's fall history. Interviews with the MDS nurse revealed that the inaccuracies were only discovered after state surveyors requested copies of the MDS assessments. The nurse acknowledged that the errors occurred and attributed them to the information 'falling through the cracks.' The facility did not have a specific policy on MDS completion, instead stating that they follow state and federal guidelines and the Resident Assessment Instrument (RAI) manual. The administrator indicated that staff communication and adherence to facility policies were intended to keep residents safe, but the documentation did not reflect the actual events that occurred.