Inaccurate MDS Fall Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected residents' falls, as identified through record reviews and staff interviews. For one resident with a history of muscle wasting and falls, documentation showed four separate falls within a nine-day period, resulting in injuries including abrasions, fractures, a closed head injury, hematoma, and laceration. Despite these incidents, the discharge MDS assessment only recorded one fall with no injury and omitted the falls with both minor and major injuries. The Administrator and DON confirmed that the MDS assessment did not accurately capture the resident's fall history and related injuries. Another resident, admitted with vascular dementia, experienced an unwitnessed fall in her room shortly after admission. Both the admission and discharge MDS assessments for this resident were coded as having no falls since admission, despite documentation of the incident. The DON confirmed the inaccuracy of the MDS assessment for this resident. This deficiency was identified during a complaint investigation and was noted as a continued non-compliance from a previous survey.