Inaccurate MDS Coding for Falls and Discharge Destinations
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents out of a sample of 24. For one resident with a diagnosis of Diabetes Mellitus, the MDS assessment was coded to indicate that the resident had experienced a fall with major injury since the prior assessment. However, both the resident and consulting staff confirmed through interviews that no such fall or injury had occurred, and a review of the clinical record did not show evidence of any fall with major injury during the relevant period. For another resident admitted with Atrial Flutter, the MDS assessment was inaccurately coded to reflect a discharge to a short-term general hospital. In contrast, the clinical nurse progress note documented that the resident was actually discharged home with medications and services. The MDS nurse confirmed in an interview that the discharge destination had been coded incorrectly on the MDS assessment. These inaccuracies resulted in assessments that did not accurately reflect the residents' actual health status and discharge locations.