Inaccurate MDS Coding for Resident Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident in the area of falls. The resident, who had a diagnosis of dementia and was severely cognitively impaired, experienced four falls between the last quarterly assessment and the significant change assessment. Two of these falls resulted in no injuries, while the other two resulted in minor injuries. However, the MDS assessment only documented one fall with no injury during this period. The MDS Coordinator confirmed, upon review of the resident's medical record and the assessment, that the correct number and type of falls were not coded, attributing the error to an oversight. The DON and Administrator acknowledged that the MDS should accurately reflect the resident's condition.