Inaccurate MDS Coding of Resident Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, resulting in an incorrect assessment record. According to the CMS RAI 3.0 User's Manual, Section J1800 and J1900 require that all falls since the last assessment be documented, including the number and whether injuries occurred. For the resident in question, the quarterly MDS indicated only one fall without injury since the last assessment. However, a review of the resident's progress notes revealed two unwitnessed falls without injury during the relevant period. During an interview, the acting DON confirmed that there were two falls and acknowledged that the MDS should have been coded to reflect both incidents. Facility policy requires accurate and comprehensive assessment documentation, with staff attesting to the accuracy of their entries.