Inaccurate MDS Coding of Bed Rails as Physical Restraints
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for several individuals. Specifically, for three residents with complex medical histories including Alzheimer's disease, Parkinson's disease, dementia, and other chronic conditions, the Minimum Data Set (MDS) assessments incorrectly coded bed rails used for positioning and turning as physical restraints. Record reviews showed that the care plans for these residents identified the bed rails as mobility or enabler bars used to assist with bed mobility, not as restraints. Observations and interviews confirmed that the residents used the side rails to help reposition themselves in bed, and staff interviews acknowledged that the MDS coding was inaccurate. The MDS nurse and the DON both confirmed that the bed rails were not being used as restraints and should not have been coded as such. The facility's policy and the RAI manual specify that bed rails are only considered restraints if they are used to intentionally prevent a person from getting in and out of bed. The incorrect coding on the MDS assessments did not reflect the actual use of the bed rails as described in the care plans and by the residents themselves.