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
Facility staff failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. The resident's admission record included diagnoses of dizziness, senile dementia, and osteoporosis. On 03/18/25, the resident experienced an unwitnessed fall, which was documented in progress notes and resulted in new physician orders for fall prevention, monitoring for injuries, and neurological checks. Despite this incident, the resident's annual MDS assessment indicated that no falls had occurred since admission or the prior assessment. During an interview, the MDS Coordinator confirmed that the MDS was inaccurate because it did not reflect the documented fall.