Failure to Accurately Code MDS Assessment for Resident Fall
Penalty
No penalty information released
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Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of falls. The resident, who had a history of right knee fracture and muscle weakness, experienced a self-reported fall resulting in a skin tear to her left hip after her admission. Despite this incident, the subsequent quarterly MDS assessment did not reflect any falls since the last assessment. Upon review, the MDS nurse confirmed that the fall with minor injury should have been coded but was missed due to oversight. The Director of Nursing stated that accurate coding of falls in the MDS is expected.