Inaccurate MDS Coding of Restraint Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident, resulting in an incorrect indication that the resident had a limb restraint. The resident, who was admitted with a diagnosis of unspecified dementia, had no documentation in the medical record to support the use of a restraint. Observations and interviews with staff, including a CNA, LPNs, and the Director of Nursing, confirmed that the resident did not have and had never had a restraint in use. A review of the resident's annual MDS assessment showed that a limb restraint was coded as being used less than daily. However, both the LPN responsible for coding and the Director of Nursing acknowledged this was an error. The facility's policy requires that all resident assessments be accurate and reflective of the resident's current status, but this was not followed in this instance, leading to the deficiency.