Incorrect Coding of Assistive Devices as Restraints
Penalty
Summary
The facility failed to ensure that assistive devices were accurately assessed and not incorrectly coded as restraints for two residents. In the first case, a resident who used a scoop mattress due to poor core control demonstrated the ability to turn, sit up, and get out of bed independently. Both the resident and staff confirmed that the scoop mattress did not restrict movement, and the resident's evaluation noted it was not used as a restraint. However, the Minimum Data Set (MDS) assessments inaccurately coded the scoop mattress as a restraint, despite evidence to the contrary. In the second case, another resident used bed rails as a mobility aid to prevent rolling out of bed and was able to sit and stand independently. Staff confirmed that the bed rails did not limit the resident's mobility or ability to get out of bed. Despite this, the resident's MDS assessments consistently coded the bed rails as being used daily, which was not accurate since they did not function as restraints. These inaccuracies in assessment and documentation led to the deficiency.