Failure to Accurately Code MDS for Resident Safety Alarms
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately coded to reflect the use of safety alarms for a resident with medically complex conditions, including hypertension, anxiety, and depression, who required extensive assistance with activities of daily living. Despite the resident's care plan and physician orders indicating the use of bed, recliner, and wheelchair alarms as fall interventions, the MDS assessment did not document the presence of these alarms. Multiple observations confirmed the resident was consistently using bed and chair alarms, and staff interviews verified that these alarms had been in place for an extended period. The MDS coordinator acknowledged that the alarms were not coded on the MDS and stated that the standard process involved reviewing assessments, care plans, and care conference notes, but a visual assessment was not performed for this resident at the time of the MDS completion. Both the MDS coordinator and nursing staff confirmed that the alarms should have been included in the MDS coding. The facility's policy required that MDS assessments consistently reflect information from progress notes, care plans, and resident observations, which was not followed in this instance.