Failure to Accurately Code Resident Falls on MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status by not documenting two unwitnessed falls that occurred on 6/1/25 and 6/18/25. The resident, who had diagnoses including dementia, muscle wasting, repeated falls, muscle weakness, and gait abnormalities, was identified as high risk for falls. The comprehensive care plan and the facility's incident log both documented the falls, but the discharge MDS indicated that no falls had occurred since admission or the prior assessment. Interviews with the ADON and DON revealed that the falls were not captured on the discharge MDS due to oversight and a lack of understanding regarding the coding requirements for falls. The ADON acknowledged missing the falls section on the MDS and was unsure of the importance of capturing this information. The DON was also unclear about the look-back period for falls in the MDS and confirmed that the omission resulted in incorrect documentation. The CMS RAI Manual specifies that any falls since admission or the prior assessment should be coded, but this was not followed in this case.