Inaccurate MDS Coding of Bed Rails as Restraint
Penalty
Summary
The facility failed to accurately code an admission Minimum Data Set (MDS) assessment for one resident. Specifically, the MDS assessment for a resident with a history of traumatic hemorrhage of the left cerebrum and severe cognitive impairment was incorrectly coded to indicate that bed rails were being used as a restraint. However, the resident's care plan documented that the side rails were in place for bed mobility and positioning, not as a restraint. Observation confirmed the presence of half side rails on the resident's bed. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed that the bed rails were not intended as restraints but rather to assist with positioning. Both staff members acknowledged the error in the MDS coding, with the DON emphasizing that the facility does not use restraints. The deficiency was identified through a review of facility policy, resident records, staff interviews, and direct observation.