Inaccurate MDS Assessments for Fall History
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, as required by the Resident Assessment Instrument (RAI) Manual. For one resident admitted with pneumonia and acute kidney failure, the quarterly MDS did not reflect a fall that occurred on February 2, 2025, despite documentation of the incident in the clinical record. Similarly, another resident with monoplegia of the upper limb experienced a fall on May 4, 2025, which was not recorded in the MDS completed on June 24, 2025. These inaccuracies were confirmed through a review of clinical records, resident observation, and staff interviews, including confirmation by the Director of Nursing and Nursing Home Administrator. The failure to accurately document fall history in the MDS assessments resulted in noncompliance with both federal and state regulations regarding resident assessment and medical records.