Inaccurate MDS Assessment Following Resident Fall
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. The resident was admitted to the facility and subsequently experienced a fall, resulting in a bruise to the side of the left eye and redness to the forehead, left shoulder, left hip, and both knees, as documented in the progress notes. However, the quarterly MDS assessment completed by staff inaccurately recorded that the resident had one fall without injury and zero falls with injury, despite clear documentation of injuries following the fall. During an interview, the MDS coordinator confirmed that the assessment was inaccurate and should have reflected a fall with injury.