Inaccurate MDS Coding of Resident Falls and Injuries
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected falls and resulting injuries for a resident with a complex medical history, including cauda equina syndrome, vertebral complications, a history of falls, dementia, and other neurological and psychiatric conditions. Despite documented incidents, including an assisted fall resulting in a cervical neck fracture and another witnessed fall without injury, the MDS assessments were coded to indicate that the resident had not experienced any falls since admission or their prior assessment. These inaccuracies were identified during interviews and record reviews, where the MDS Coordinator acknowledged that the assessments should have reflected the actual fall events and their outcomes. The deficiency was further substantiated by facility policy, which requires comprehensive and accurate assessments, and by statements from both the Director of Nursing and the Administrator, who confirmed that MDS assessments are expected to be complete and accurate. The failure to review the medical record and accurately code the MDS assessments led to the omission of significant fall events and injuries in the resident's official assessment documentation.