Inaccurate MDS Coding for Restraints, Infections, and Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents in the areas of restraints, infections, and falls with major injury. For one resident with epilepsy, the quarterly MDS assessment indicated daily use of bedrails as restraints, but direct observation and interviews revealed that no side rails were in use and the resident was unable to use them for positioning or support. The Nurse Assessment Coordinator admitted to incorrectly coding the MDS due to inexperience in the role. Another resident with chronic obstructive pulmonary disease, diabetes mellitus, and latent tuberculosis was incorrectly coded on the MDS as having active tuberculosis. Review of the medical record showed no treatment for TB, and both the resident and the Nurse Practitioner confirmed that the resident only had latent TB and no active disease. The Nurse Assessment Coordinator acknowledged the error, attributing it to a mistake made while learning the MDS process. A third resident, diagnosed with dementia and muscle weakness, experienced a fall resulting in a fractured finger. Despite documentation of the injury and subsequent treatment orders, the quarterly MDS assessment failed to indicate a fall with major injury. The MDS Coordinator confirmed the omission was an oversight. In all cases, facility leadership, including the DON and Administrator, stated that MDS assessments are expected to accurately reflect residents' clinical status and care needs.