Inaccurate MDS Coding for Falls and Discharge Status
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, resulting in inaccurate documentation of falls and discharge status. For one resident, the quarterly MDS did not reflect two falls that had occurred since admission, despite these incidents being documented in the electronic medical record. Both the nurse manager and interim DON confirmed that these falls should have been included in the MDS assessment. For another resident, the discharge MDS was incorrectly coded as a transfer to a short-term general hospital, while the electronic medical record and progress notes indicated the resident was actually discharged home with family. Facility staff acknowledged the MDS was coded incorrectly and verified the actual discharge destination. No facility policy on MDS completion was provided when requested. These inaccuracies in MDS coding were identified through interviews and document review, with staff confirming the errors and the discrepancies between the MDS and the residents' medical records.