Failure to Accurately Code Use of Restraints on MDS
Penalty
Summary
The facility failed to accurately code the use of restraints on the Minimum Data Set (MDS) for two residents who utilized a Merry Walker device. Both residents had severe cognitive impairment, as indicated by low BIMS scores, and required assistance for ambulation. Documentation and interviews revealed that both residents were regularly placed in the Merry Walker, could not remove themselves from the device independently, and were supervised or assisted by staff for mobility and toileting. Despite this, the use of the Merry Walker was not identified or coded as a restraint on the MDS, nor was it consistently addressed in the care plans as a restraint. Staff interviews confirmed that the residents were unable to exit the Merry Walker without assistance, and that the device was used for extended periods throughout the day. Registered nursing staff acknowledged during interviews that the Merry Walker should have been documented as a restraint on the MDS and included in the care plan, but this was not done. The failure to accurately assess and code the use of the Merry Walker as a restraint constituted the deficiency identified during the survey.