Inaccurate MDS Assessment Coding for Resident with Hip Fracture
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident who experienced a displaced fracture of the right hip. Medical record review showed that the resident had a physician's order for an x-ray and doppler study, and the x-ray confirmed a displaced fracture. The resident was subsequently sent to the emergency room for further evaluation. Additionally, the resident's Medication Administration Record (MAR) documented administration of Tramadol, an opioid medication, for pain management on two occasions prior to the assessment reference date. Despite these documented events, the MDS assessment with a reference date corresponding to the incident did not capture the fracture in Section I (diagnoses) or the use of Tramadol in Section N (medications). During staff interviews, it was confirmed that these omissions occurred, and it was noted that the facility was without an MDS coordinator at the time, though new staff had recently been hired. The deficiency was identified during a complaint survey and confirmed through both record review and staff interview.